**Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis 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 -

I hereby authorize InfiniTrim® LLC, & his associates to obtain and use information about my credit history and all information on this Application, and I authorize the release of such information to InfiniTrim® LLC.
Each applicant certifies that he/she is 18 years of age or older (19 in, AL). By clicking the "Submit" button below, I authorize any doctor or other medical provider to release to 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 Financing Account. We comply with Section 325 of the USA Patriot Act. This law mandates that we verify certain information about you while processing your Account application. 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. This information is required to process your application. The Provider (the seller of goods or services) is responsible for delivering to each applicant the Financing Account. Agreement which sets forth your payment and other obligations relating to the financing of your procedures and/or purchases. You agree that we may contact you about your account, including for customer service or collection at any address or telephone number as well as any cellular telephone number you provided us.
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.