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Instant Credit Application for the Press On Veneers Special Payment Program

By completing this form, you agree that you have familiarized yourself with the New Removable Dental Veneers by Brighter Image Lab and are prepared to cosign a purchase. If you’re unsure, have questions or would like more information about Removable Dental Veneers before proceeding, please click here to return to our main page or chat with a live rep.

Confirm Your Billing Address

(No P.O. Boxes Accepted)

First Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Residential Status:

Years At Residence:

Monthly Housing Payment:

Applicant For Which You Are Cosigning:

Verify Your Personal Information

Cell Phone:

Email Address:

Date of Birth:

Social Security Number:

Are You A U.S. Citizen?

YesNo

Driver's License Number:

Issuing State:

Verify Your Employment Information

Employer's Name:

Job Position:

Employer Address:

City:

State:

Zip Code:

Work Phone:

How long have you worked there?

Gross Monthly Income:

Other Monthly Income:

See my social media profile:

(optional - helps for faster approval)

Facebook:

Google+:

LinkedIn:

Are you ready to cosign for Press On Veneers?

Yes, I have made up my mind and I agree to move forward with Press On Veneers Special Payment Program. Please contact me by phone and/or email to review my cosign agreement.

By clicking “I’m Ready”, I agree that I will be responsible for all payments for which the applicant does not make. I confirm that I have read the E-Sign Consent and I agree to have the Terms & Conditions presented electronically. By submitting this form I hereby authorize and instruct Brighter Image Lab to obtain and review my credit report. My credit report will be obtained from a credit reporting agency chosen by Brighter Image Lab. I further authorize Brighter Image Lab to share with third party financial providers any information that I have provided. These financial providers may contact me or the applicant to discuss details or offers for which they may be eligible based on my credit report. I hereby swear or affirm that all information provided is true and accurate.

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