Weight Loss Surgery Direct

Weight Loss Surgery Direct Financing Application

Date of Birth *

Do You Have Any Additional Monthly Income? *

If Yes, What is the Average Amount Per Month?

If Yes, What's The Source of Your Additional Income

Surgery Type

Do You? *

$ Monthly Rent / Mortgage

Years At Residence *

Home Phone *

Work Phone

Mobile/Cell Phone

Employer's Phone *

Email *

Are You Married? *

Agreement

I certify that the above information is completely true and accurate. I authorize Weight Loss Services, Inc and/or assigns to check my credit record and verify my credit and employment history.

Date *

Social Security *

I Have Read & Agree To The Terms Above *

How Did You Here About Us? *

If Other, Please Specify

Comments or Questions	Under Writer Remarks

Spouse Details

Do You Have Any Additional Monthly Income? *

If Yes, What is the Average Amount Per Month?

If Yes, What's The Source of Your Additional Income

Surgery Type

Need Co-Signor?

Do You? *

$ Monthly Rent / Mortgage

Years At Residence *

Home Phone *

Work Phone

Mobile/Cell Phone

Employer's Phone *

Email *

Are You Married? *

Agreement

I certify that the above information is completely true and accurate. I authorize Weight Loss Services, Inc and/or assigns to check my credit record and verify my credit and employment history.

Date *

Social Security *

Date of Birth *

I Have Read & Agree To The Terms Above *

How Did You Here About Us? *

If Other, Please Specify

Comments or Questions	Under Writer Remarks

By submitting this application I have verified that all information submitted on this application is true and correct to the best of my knowledge, as well as allowing WEIGHT LOSS SERVICES, INC. and/or its Lender(s) to verify the enclosed information, including, but not limited to, obtaining my credit report, contacting my employer to verify employment and income, and/or contacting my Physician to verify the type of procedure(s), procedure date, deposit amount, procedure amount and remit payment on approval.