Friday, March 12, 2010
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Addiction Treatment Financing Application
Financing Application
The Cedars Rehabilitation Center offers a unique and affordable treatment program. We are also pleased to be able to assist you in obtaining financing for treatment. Please take a moment to fill out and submit the secure and confidential form below. A Counselor will contact you once the application has been received.
First Name*
Middle Name*
Last Name*
Email Address*
Address
City
State
Zip
Phone*
Mobile Phone
Own Home or Rent Own
Rent
Rent/Mortgage Payment Amount
How Long at Current Address?
Previous Address
If Less Than 1 Year at Current Address
Previous City
Previous State
Previous Zip
Social Security Number*
Date of Birth*
Employer Name
How Long at Current Employer?
Gross Annual Salary $
Other Income
Source of Other Income
Alimony, child support or seperate maintenance income need not be revealed if you do not wish to have it considered as a basis for paying the loan.
Driver's License #
Have you ever filed for Bankruptcy? Yes
No
If Yes, how long ago?

* Required Field
All personal information submitted to The Cedars Rehabilitation Center is secure and strictly confidential.

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