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mexico dentists

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APPOINTMENTS CONTACTS
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Our Office Located at::
929 Blvd. Sanchez Taboada
Suite 4, Rio Zone Tijuana BC. Mexico
In Plaza Serena next to Hotel Monaco
(North end of COSTCO)
US Mailing Address:
P.O. Box 131341San Diego, CA, 92170
No soliciting under any condition
Dial from San Diego (619) 446-6345
Dial from Los Angeles (213) 291-3518
Dial from San Diego (664) 685-7020

AMERICAN DENTAL INSURANCE
		123 Dental Plan - Insurance Plans
		Aetna U.S. Healthcare - Insurance Plans
		Affinity Insurance - Insurance Plans
		Benefit Plans of America, Inc - Individual Comprehensive Dental Plan
		California Health Insurance - Dental Plan
		Delta Dental - Dental Plan
		Dental Benefit Providers - Dental Benefit Company
		DentalCALL - Dental Plan
		Insurance Company - Dental Insurance
		Travel Insurance - Travel Insurance from JS Insurance
		MetLife Dental Care - Insurance
		National Integrated Health Associates - Dental Health Care
		The Best Affordable Dental Plan - Dental Plan
		Delta Dental Plan of California - Dental Plan
		Dental Insurance- Dental Care

FINANCING
	To apply, please answer each question, unless marked optional. If there is a co-applicant, you must provide all co-applicant information, in addition to applicant information. IMPORTANT: You will see the terms and conditions at the end of this page. You MUST approve the terms and conditions for the application to be complete. If you have not clicked. "YES" on the terms and conditions section, you have not completed the application. Please follow the directions carefully as you through the process. Thank you for applying!

APPLICANT INFORMATION:
		First Name:

		Middle Name:

		Last Name:

		Email:

		Address


		City	State:

		Zip:	Phone Number


		Date of Birth:	SSN:

		Driver Lic.#:	Expires:

APPLICANT EMPLOYER INFORMATION:
		Employer:	Occupation:

		Phone Number:	Email:

		Gross Salary Monthly: Employment Length:
		years months
ADDITIONAL INFORMATION:
		Home Information: Own Rent Other
		Length at Residence: years months
		Monthly Payment:	Other Income:

NEAREST RELATIVE NOT LIVING WITH YOU AND NOT THE CO-APPLICANT:
		First Name:	Middle Name:

		Last Name:	Relationship:

		Phone:

CO-APPLICANT INFORMATION:
		First Name:	Middle Name:

		Last Name:	Address:

		City:	State:

		Zip:	Phone Number:

		Date of Birth:	SSN:

		Drives Lic. #:	Expires:

CO-APPLICANT EMPLOYER INFORMATION:
		Employer:	Occupation:

		Phone Number:	Email:

		Gross Salary:
		monthly
		Employment Length: years months
ADDITIONAL INFORMATION:
		Home Information: Own Rent Other
		Length at Residence: years months
		Monthly Payment:	Other Income:

NEAREST RELATIVE NOT LIVING WITH YOU AND NOT THE CO-APPLICANT:
		First Name:	Middle Name:

		Last Name:	Relationship:

		Phone:

PROCEDURE INFORMATION:
		Type of Procedure:	Doctor:

		Phone Number:	Amount Requested:

TERMS AND CONDITIONS
All the information on this form is complete, correct and provided to Trust Dental Care's Financial Institution to obtain an installment loan or credit loan. I/we authorize Trust Dental Care's Financial Institution to investigate credit and employment history and to report the credit experience of any party or authorized user to consumer reporting agencies and others. I/we understand that Trust Dental Care's Financial Institution will retain this application whether or not it is approved. I/we understand that if the application is for a secured loan by real property that additional information is required. I/we certify that I am/we are 18 years or older and have completed the application questions accurately at any time after this application and/or during my/our relationship with Trust Dental Care's Financial Institution. I/we authorize Trust Dental Care's Financial Institution to obtain information concerning my/our employment and credit standing and authorize my/our employer, banks and/or other listed references to release information to Trust Dental Care's Financial Institution. Trust Dental Care's Financial Institution may review from time to time my/our eligibility for any credit extended on the account and may provide information about me/us to others. If I/we designate other authorized users, credit bureaus may receive account information on the authorized users in each users name. I/we agree to notify Trust Dental Care's Financial Institution immediately upon any material change in the information I/we provided herein. I/we affirm that each of the answers given to the foregoing questions is true and correct and that the foregoing is a true and correct statement of my/our financial condition. It is a federal criminal offense to knowingly make any false statement or report, or to willfully overvalue any property for the purpose of influencing Trust Dental Care's Financial Institution to act on this application.
I / we understand and agree to the terms and conditions of this application: Yes No

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Dental Office: 929 Blvd. Sanchez Taboada Suite 4, Rio Zone 22915
Telephone: From San Diego (619) 446-6345 From Los Angeles (213) 291-3518 From Tijuana (664) 685-7020
E-mail: cynthia@dentistattijuana.com

Copyright 2006 / 2008. All rights reserved.