Residents Medical Group, Inc – Client Financing

Personal Information

First Name(Required)

Middle Name

Last Name(Required)

Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Own Or Rent(Required)

Time At Address(Required)

Monthly Payment(Required)

DOB(Required)

SSN(Required)

Phone Number(Required)

Email Address(Required)

Income/Employment Information

Employer Name(Required)

If you are self employed, list "self employed" as the Employer.

Employer Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation / Title(Required)

What is your job title or the industry you work in?

Phone Number(Required)

Length of Employment(Required)

Average Income(Required)

Income Period(Required)

How often are you paid?

Payment Information (ACH)

We collect two (2) forms of payment; Credit/Debit Card & ACH.

Bank Name(Required)

Account Number(Required)

Routing Number(Required)

Account Type(Required)

Payment Information (Card)

We collect two (2) forms of payment; Credit/Debit Card & ACH.

Card Number(Required)

Card Brand(Required)

Expiration Month(Required)

Expiration Year(Required)

CVV(Required)

Two References

Please provide two references. They will be no outreach to the references provided unless the customer defaults on payments and avoids all collection efforts.

Reference #1

First Name(Required)

Last Name(Required)

Phone Number(Required)

Relationship(Required)

Reference #2

First Name(Required)

Last Name(Required)

Phone Number(Required)

Relationship(Required)