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The undersigned acknowledges that the information supplied above is for the purpose of obtaining credit and hereby certifies that all information is true and correct. Further, the undersigned authorizes ChiroTouch and any credit agency or investigatory service engaged by ChiroTouch to conduct a credit investigation which may include obtaining consumer credit reports, as ChiroTouch deems appropriate. The undersigned agrees to release all persons, companies, or corporations using or supplying such information, including ChiroTouch, from any claims and/or losses that may result therefrom.
I have read and understand this form in its entirety, all information herein is accurate, and certify that I am the lessee(s) listed above.
NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract); because all other part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning the creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, D.C. 20580. If your application for credit is denied, the Equal Credit Opportunity Act, Regulation B stipulates that you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact ChiroTouch within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days for receiving your request for the statement.