Patient Financing | Lending Club

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Patient name

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Applicant Information

Applicant name

Home Address

Is your mailing address the same as your home address?YesNo

Primary PhoneNumber

Email Address

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Date of Birth

Social SecurityNumber

Employment Status

Employer Name

Job Title

Total Annual Income

Some examples of income include the following:
Income from employment, including full-time, part-time, freelance, or seasonal jobs
Self-employment, including any business dividends or rental income
Any other income such as retirement, social security, or public assistance
Important notes:
• Non-taxable income, if included, should be increased by 25%.
• Alimony, child support or separate maintenance income need not to be included if you do not wish to have it considered as a basis for repaying this obligation.
• Married Wisconsin Residents Only: If you are applying for an individual account and your spouse is also a WI resident, combine your and your spouse’s financial information.

Monthly Mortgageor Rent

By checking this box, you acknowledge that you have received, read, and agree to all of the terms of the E-Sign Consent.

By checking this box, you acknowledge that you have received, read, and agree to all of the terms of the Application Terms and Conditions.

By checking this box, you acknowledge that you have received, read, and agree to all of the terms of the Credit Profile Authorization, and LendingClub Privacy Policy.

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

Checking to see what options you prequalify for generates a soft credit inquiry on your credit report, which is visible only to you. A hard credit inquiry, which is visible to you and others, and which may affect your credit score, only appears on your credit report when you either obtain an Installment Loan or complete your application for a Credit Account with a promotional plan.

Credit terms will depend upon credit score and other key financing characteristics, including but not limited to the amount financed, loan term length, and your credit usage and history. Applications are subject to credit approval.

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Applicant Information