Application And Credit Card Account Agreement (Page 2 of 10) in pdf

APPLICATION AND CREDIT CARD

For Providers: (800) 859-9975

ACCOUNT AGREEMENT

For Patients/Clients: (800) 365-8295

Credit is extended by GE Capital Retail Bank

Submit by Internet:

** MARRIED WI Residents only: If you are applying for an individual account and your

spouse also is a WI resident, combine your and your spouse’s financial information.

Office Merchant #

Pre-Approval Offer

ESTIMATED FEE $

q Accepted q Refused Date ______________

Photo ID verified (initial): Applicant 1st ID Type / Number

Issuance State

Exp. Date

Applicant 2nd ID Type / Issuer

Exp. Date

# _______________________________________________________

Driver’s License

State Issued

Federal Government

Account #

Authorization # or Key #

Approved Credit Limit

Provided by

GE Capital Retail Bank:

1. APPLICANT INFORMATION: Please tell us about yourself.

Please note that you must reside in the United States and be 18 years or older to apply.

Name (First-Middle-Last) Please Print

Date of Birth

Social Security Number

Home Phone Number*

(

)

Mailing Address

Apt.#

City

State

Zip

Cell/Other Phone Number*

(

)

Your Address?

Contact Person?

If the above address is a P.O. Box, you must provide a street address for yourself or a contact person.

City

State

Zip

Contact Person Name

Street Address (Street Name and Number)

Housing Information

Nearest Relative Phone

Alimony, child support or separate maintenance

Monthly Net Income

Employer’s Phone Number*

Number*

income need not be included unless relied upon

From All Sources

PARENTS/RELATIVE

for credit. You may include the monthly amount that

OWN

RENT

OTHER

(

)

you have available to spend from your assets.

(

)

$_____________________

*You authorize GE Capital Retail Bank (“GECRB”) to contact you at each phone number you have provided. By providing a cell phone

E-Mail Address (optional)*

number and/or email address, you agree to receive special offers, updates and account information, including text messages, from

CareCredit, LLC, providers that accept the CareCredit credit card and GE Capital Retail Bank. Standard text messaging rates may apply.

2. JOINT INFORMATION:

An additional card will be issued to the person indicated below. The applicant (and joint applicant, if any) will be liable for all transactions

made on the account including those made by any authorized user. JOINT APPLICANT: You agree that we may send notices to you and/or applicant at the applicant’s

address, regardless of whether you live at that address.

Name (First-Middle-Last) Please Print

Date of Birth

Social Security Number

Home Phone Number *

(

)

Mailing Address

Apt.#

City

State

Zip

Cell/Other Phone Number *

(

)

Your Address?

Contact Person?

If the above address is a P.O. Box, you must provide a street address for yourself or a contact person.

City

State

Zip

Contact Person Name

Street Address (Street Name and Number)

Housing Information

Nearest Relative Phone

Alimony, child support or separate maintenance

Monthly Net Income

Employer’s Phone Number *

income need not be included unless relied upon

Number *

From All Sources

PARENTS/RELATIVE

for credit. You may include the monthly amount that

you have available to spend from your assets.

OWN

RENT

OTHER

(

)

$_____________________

(

)

Joint Applicant ID Type / Number

Exp. Date

Joint Applicant 2nd ID Type / Issuer

Exp. Date

Issuance State

# _____________________________________________________________

Driver’s License

State Issued

Federal Government

E-Mail Address (optional)*

*You authorize GE Capital Retail Bank (“GECRB”) to contact you at each phone number you have provided. By providing a cell phone

number and/or email address, you agree to receive special offers, updates and account information, including text messages, from

CareCredit, LLC, providers that accept the CareCredit credit card and GE Capital Retail Bank. Standard text messaging rates may apply.

3. APPLICANT and JOINT APPLICANT: We need your signature(s) below.

By applying for this account or accepting a prescreen offer, I am asking GE Capital Retail Bank (“GECRB”) to issue me a CareCredit Credit Card (the “Card”), and I agree that:

• I am providing the information in this application to GECRB, CareCredit LLC, and providers that accept the Card and program sponsors. GECRB may provide information

about me (even if my application is declined or my account is not opened) to CareCredit LLC, providers that accept the Card and program sponsors (and their respective

affiliates) so that they can create and update their records, and provide me with service and special offers.

• GECRB may obtain information from others about me (including requesting reports from consumer reporting agencies and other sources) to evaluate my application or determine

whether to open my account, and to review, maintain, or collect my account.

• I consent to GECRB and any other owner or servicer of my account contacting me about my account, including using any contact information or cell phone numbers I provide,

and I consent to the use of any automatic telephone dialing system and/or an artificial or prerecorded voice when contacting me, even if I am charged for the call under my

phone plan.

• I have read and agree to the credit terms and other disclosures in this application, and I understand that if my application is approved or an account is opened, the GECRB

credit card account agreement (“Agreement”) will govern my account. Among other things, the Agreement: (1) includes a resolving a dispute with arbitration provision

that limits my rights unless I reject the provision by following the provision’s instructions; and (2) makes each applicant responsible for paying the entire amount of

the credit extended.

PLEASE SEE NEXT PAGE FOR RATES, FEES AND OTHER COST INFORMATION.

Federal law requires GECRB to obtain, verify and record information that identifies you when you open an account. GECRB will use your name, address, date of birth,

and other information for this purpose.

If I have been pre-approved, I request that you open the type of account for which I was pre-approved. I have read the Prescreen Disclosures, credit terms and other disclosures on

the next pages and have been provided my credit limit applicable to the account. GECRB reserves the right to refuse to open an account in my name if GECRB determines that I no

longer meet GECRB’s credit criteria or if I do not have sufficient income.

If you apply with a Joint Applicant, each of you will be jointly and individually responsible for obligations under the Agreement and by signing below, you each agree that you

intend to apply for joint credit.

Signature of Applicant

Signature of Joint Applicant (If Applicable)

____________________________________________________________

Date___________________

____________________________________________________________

Date___________________

(Please Do Not Print)

182-077-00

PLEASE READ THE GE CAPITAL RETAIL BANK CREDIT CARD ACCOUNT AGREEMENT

Revision Date: 062413

BEFORE SIGNING THIS APPLICATION.