Credit Application

First Name*

Middle Initial

Last Name*

Email*

Date Of Birth*

Social Security #*

Phone*

Current Address*

Street Address City State ZIP Code

Requested Treatment*

What is your monthly budget for this procedure?

Housing

How Long at Current Residence*

Housing Type*

Current Housing Payment*

Previous Address*

Street Address Address Line 2 City State ZIP Code

How long at previous residence*

Housing Type*

Employment

Employment Status*

Current Employer

Position

Current Employer Address

Street Address Address Line 2 City State ZIP Code

How long have you been with this employer? (years and months)

If currently unemployed fill out previous employment info.

Previous Employer

Length of Employment?

Previous Position

Previous Employer Address

Street Address Address Line 2 City State ZIP Code

Income

Monthly Gross Household Income*

This is your MONTHLY income before taxes.

Additional Income Source

Do you have a Co-Applicant? Insert their name, and please also have them fill out a credit app.*

Other Source of Income

Please Explain

Addition Income Amount

I the applicant have agreed for Dream Dental to run a credit application. I understand the above credit unions may run and review my credit report and personal information to approve a loan product for future treatment with Dream Dental. This is not an obligation on my part to comment to treatment or using any credit offer that may be extended to me for payment of the services provided by Dream Dental, it is only provided as an extended service at Dream Dental in exploring my financial options.

By checking the box below you are agreeing to the above statement.*

I Agree