Financing PressOn Veneers | Brighter Image Lab Official Site

First Name:

Middle Name:

Last Name:

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Driver's License Number:

Issuing State:

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Armed Forces AmericaArmed Forces AfricaAlabamaAlaskaArmed Forces PacificArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaFederated States of MicronesiaGuamGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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Residential StatusRentOwn

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Monthly Housing Payment:

Are You The Primary Resident?

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Credit Card Number:

Arch Selection:

---Press On Veneers Single ArchPress On Veneers Double Arch

Would you like to add express or warranty?
(Fees charged with down payment)

Are you ready to purchase Removable Dental Veneers?

By clicking “Yes”, I agree that the payment information I submit will be the method by which I will pay my initial down payment ($149 for single arch/$298 for double arch), and 3-Way Shipping and Processing ($46 for single/$92 for double) for a total up-front cost of $195 for a single arch/$390 for a double arch plus any optional fees I have chosen above - and that this amount can be charged immediately. I understand this charge will be refunded if it is determined that my application cannot be approved.

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 MSC Development to obtain and review my credit report. My credit report will be obtained from a credit reporting agency chosen by MSC Development. I further authorize MSC Development as a third party financial provider any information that I submit, with Brighter Image Lab. 3rd party providers may contact me to discuss details or offers for which I may be eligible. I hereby swear or affirm that all information provided is true and accurate.