:::Angel Body :::

Credit Application

* Required Fields

Applicant Information

First Name*

MI*

Last Name*

Social Security Number *

Street*

Apt#*

Phone / Alt Phone (e.g. mobile)*

Date of Birth*

No. of Dependents*

City *

St*

Zip*

Time at Address (y/m)*

Email Address*

Previous Street (if 1 year at present address) *

Previous City*

St.*

Zip*

Driver's Licence Number *

Employer*

Ocupation*

Employer's Phone *

Time at Employment: yrs / mths*

Previous Employer*

Select one *

Rent

Own

Other

(Type?)

Gross Salary*

per:*

Other Income $/per

Source

Rent / Mortgage Amount $*

Relative Not Living with You: Name, Ph & Relationsip*

If you wish add the Co-Applicant Information, please, write all the requested fields.

Co-Applicant Information

First Name

Last Name

Social Security Number

Street

Apt#

Phone / Alt Phone (e.g. mobile)

Date of Birth

No. of Dependents

City

Zip

Time at Address (y/m)

Email Address

Previous Street (if 1 year at present address)

Previous City

St.

Zip

Driver's Licence Number

Employer

Ocupation

Employer's Phone

Time at Employment: yrs / mths

Previous Employer

Select one

Rent

Own

Other

(Type?)

Gross Salary

per:

Other Income $/per

Source

Rent / Mortgage Amount $

Relative Not Living with You: Name, Ph & Relationsip

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 offence to knowingly make any false statement or report, or to wilfully overvalue any property for the purpose of influencing the Cogent Financial to act on this application.

Dr. Joaquín Merlos, Av. Guadalajara 6908 Col. Guanajuato Tijuana, B.C. México, US Toll Free: 01 (866) 364-5747
from US direct phone (619) 207-4378 from Mexico 01 (664) 626 1526