Single Finance Application

Financing Application - Single Applicant

Your Information:

First Name: Last Name:

Home Phone: Work Phone: Email:

Address: City: State: Zip:

Social Security Number: Date of Birth: Marital Status: Dependents:

Home Ownership:

Home Ownership Status: Length of Time at Current Residence:

Monthly Payment: Mortgage Company / Landlord:

Employment History:

Occupation: Company Name: Work Phone:

Time at Current Employment: Annual Income: Other Income Sources:

Unit of Purchase: Please select your Life Ionizer from the drop down: Select Ionizer Options:

EF Technology ($150.00) MESH ($100.00)

UV Light Technology ($150.00) MESH UV ($250.00)

Employment History:

Nearest Relative 1 Name: Relative 1 Relationship to Applicant:

Relative 1 City: Relative 1 State: Relative 1 Zip:

Relative 1 Country: Relative 1 Phone:

Nearest Relative 2 Name: Relative 2 Relationship to Applicant:

Relative 2 City: Relative 2 State: Relative 2 Zip:

Relative 2 Country: Relative 2 Phone: