United Credit Personal Loan Application

Person Receiving Services

Is Applicant the Person Receiving Services? *

Yes No

Loan Information

Amount Requested (up to $) *

Purchase Type *

Date of Purchase *

Date must be within 60 days. If not yet set, please provide an estimate.

Merchant

Miami Men's Clinic (Modern Men's Clinic, LLC)

Applicant

First Name *

Middle Name

Last Name *

Social Security Number *

Confirm Social Security Number *

Date of Birth *

Email *

Confirm Email *

Please enter your correct personal email address to avoid processing delays

Cell Phone Number *

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)

Home Phone Number

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Home

Address (no P.O. Boxes) *		Apartment #		City *
State *		Zip Code *		Monthly Mortgage/Rent Payment ($) *

Source of Personal Income

Employment Status * Please check this box if any of your income is non-taxable (e.g. Retirement, Child Support, Alimony) Tax returns required. Total Gross Monthly income should be based off Adjusted Gross Income on returns.		Total Monthly Income Before tax ($) * Input the GROSS income you personally receive MONTHLY from your employment. Income may be subject to verification.		Other Personal Verifiable Monthly Income ($) Income from alimony, child support or separate maintenance payments need not be disclosed if you do not wish to have this income considered as a basis for repaying this obligation.
Total Annual Income ($)		Please check Total Annual Income is correct

Employer Name *

Agreement

By clicking the 'Submit application' button, you are providing written consent under the Fair Credit Reporting Act for United Credit and our lenders and partners with whom you are matched to obtain consumer reporting information from your credit profile or other information from one or more credit bureaus. You understand and agree that you are requesting prequalification for credit, and are consenting to the use of your consumer report information by United Credit and our lenders and partners to conduct anti-fraud security checks and evaluate your request. You understand that your application may be matched with multiple lenders, each of whom may obtain consumer report information from your credit profile. You also direct United Credit to share your information with other lenders and partners who may use that information to consider whether to prequalify you to apply for financing.

I have read and accept the Agreement, Privacy Policy, Terms, Additional Disclosures, Electronic Disclosure and Personal Credit Pull Authorization. *

By clicking the 'Submit application' button, you agree that your electronic signature has the same legal meaning, validity and effect as your handwritten signature.

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