**Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered for repaying this obligation.
Married Wisconsin residents: If you are applying for an individual account or a joint account with someone who is not your spouse, combine your and your spouse's information on this application.
State Notices - California Residents: A married applicant may apply for a separate credit account. After credit approval each applicant shall have the right to use this Account to the extent of any credit limit set by the creditor, and each applicant may be liable for all amounts of credit extended under this Account to any joint applicant. Maryland & Delaware Residents: Finance charges not in excess of those permitted by law will be charged on the outstanding balances from month to month. Maine & New York Residents: We may request a consumer report from consumer reporting agencies in considering this Application and subsequently for the purpose of updates, renewals or extensions of credit granted as a result of the Application. Upon applicant's request we will inform applicant of the name and address of each consumer reporting agency from which we obtained a consumer report, if any, relating to applicant and co-applicant. Ohio Residents: The Ohio laws against discrimination require that all creditors make credit equally available to all credit-worthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio civil rights commission administers compliance with this law.
I hereby authorize William H. Swearingen D.D.S. to obtain and use information about my credit history and all information on this Application, and I authorize the release of such information to William H. Swearingen D.D.S.. Federal law requires us to obtain, verify and record information that identifies you when you open an account. We will use your name, address, date of birth, and the other information for this purpose. Each signatory certifies that he/she is 18 years of age or older. By clicking the "Submit" button below, I authorize any doctor or other medical provider to release to William H. Swearingen D.D.S. any information and records regarding my medical or dental procedures, treatments, devices, implants and other medical or dental services and products financed by means of the William H. Swearingen D.D.S. Revolving Account. The Merchant (the seller of goods or services) is responsible for delivering to each applicant the Revolving Account Agreement and Disclosure Statement, which sets forth your payment and other obligations relating to the financing of your procedures and/or purchases. William H. Swearingen D.D.S. will maintain a copy of the credit approval or denial. I understand I am also entitled to a copy of the credit approval or denial and that I will receive a copy of it.
Cosmetic and General Dentistry