New Application

Review the application details below and obtain the customer's signature before proceeding.

Applicant Information

Applicant Name Business/Work Phone Date of Birth Mobile Phone Email Address Applicant Address

123 Main Street
OH 45419

Social Security Number/ITIN Housing Type Home Phone Monthly Net Income

Driver’s License

Expiration Date Expiration Date Applicant Name Business/Work Phone Date of Birth Mobile Phone Email Address Applicant Address

123 Main Street
OH 45419

Social Security Number/ITIN Housing Type Home Phone Monthly Net Income

Passport

Expiration Date

Green Card/Resident Alien Card

Expiration Date You must confirm that the customer has signed and dated a paper copy of the Application

I certify that the application information was provided by the applicant. I have provided all required notices and statements, including a copy of the CareCredit Application which contains the Credit Card Account Agreement terms, to the applicant prior to submitting this application. I am submitting this application on behalf of the applicant based on the applicant having signed either (i) a printed version of this online application (in English or Spanish, as applicable) or (ii) a pre-printed paper copy of the CareCredit Application (in English or Spanish, as applicable).

Application Revision Date

If using a paper version of the CareCredit Application, ensure that the latest Terms and Conditions are provided by entering the Application Revision Date (MMDDYY) in the field above. The Application Revision Date can be found on the lower left corner of the Application cover page and under the Applicant signature box.