Obesity Goodbye Center

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Medi-Credit Aplication	1-866-446-2373 (Toll Free)
	(619) 209.73.51 \| (619) 754.49.62

To apply, please answer each question, unless marked optional. If there is a co-applicant, you must provide complete information of the co-applicant, on step 2 of this application process, in addition to the applicant's information.

IMPORTANT-PLEASE READ: The terms and conditions are available at the end of this application. The Bank will assume that if you have filled out any part of this application, then you agree with the terms and conditions. To complete the application, you must click 'YES' on the terms and conditions section, which is the last step of the application process.

There are 4 steps beyond this page. When entering numbers, please do not use any punctuation, such as "-" or "/" or "(". Please follow the directions carefully to ensure we receive all of your information. Thank you for applying

STEP 1

Applicant Information
First Name		Last Name
Address		City
State	Zip	Email
Phone	-	Alt. Phone	-
Date of Birth	/ /19	SSN	- -
Applicant Employer Information
Employer		Address
City		State	Zip
Phone	-	Position
Gross Salary	per:	Employment Length	Yrs. Mos.
Additional Information
Home Information	Own Rent Live w/Relatives Other	Length at Residence	Yrs. Mos.
Rent/Mortgage Amount	$	Additional Income	per:

STEP 2

If you have a co-applicant that will also be signing up with you please enter his or her information below. If you don't have a Co-Applicant, please click here:

Co-Applicant Information
First Name		Last Name
Address		City
State	Zip	Email
Phone	-	Alt. Phone	-
Date of Birth	/ /19	SSN	- -
Co-Applicant Employer Information
Employer		Address
City		State	Zip
Phone	-	Position
Gross Salary	per:	Employment Length	Yrs. Mos.
Additional Information
Home Information	Own Rent Live w/Relatives Other	Length at Residence	Yrs. Mos.
Rent/Mortgage Amount	$	Additional Income	per:

STEP 3

You are requesting this for a specific type of procedure, please provide us with as much information as possible.

Procedure Information
Type of Procedure	Adjustable Gastric Band	Procedure Date	/ /20
Request Amount	$	Requested Term	Mos.

STEP 4

Authorization
I/we understand that by providing the information above, which information I/we certify to be true and accurate to the best of my knowledge, I/we am authorizing and requesting a loan from or through Cogent Financial, or its partners to finance a medical procedure(s). I/we hereby authorize you/your agents, partners, transferees and assigns to obtain any credit reports and information you/they deem necessary to complete your/their credit review and to assign, sell or transfer any obligation resulting from this application to any individual, company or institution of your/their choice. I/we understand that this application will be retained whether approved or not. I/we certify that I/we am/are 18 years of age or older and have completed the application accurately. I/we agree to notify Cogent Financial immediately upon any material change in the information I/we provided herein.
I/we affirm that each of the answers given to the foregoing questions is true and correct and that the foregoing is a true and correct statement of my/our financial condition. It is a federal criminal offense to knowingly make any false statement or report, or to willfully overvalue any property for the purpose of influencing the Cogent Financial to act on this application.
Method of contact
If you selected fax, please enter your fax number

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