LendingClub in ReUnite Assist

Estimated Amount

Please enter an amount between $2,000 to $10,000. The minimum amount in Massachusetts is $6,001.

Patient Name

Email
Patient is my

Mailing Address

Enter street address.

Is your mailing address the same as your home address?

Yes No

Primary Phone By providing your phone number, you agree to be contacted at that number from LendingClub Patient Solutions regarding your application or relationship with us, including by automated dialer pre-recorded or artificial voice.

Date of Birth (MM/DD/YYYY)

Age limit 18 to 108 years

Social Security Number
Your social security number is used to obtain consumer reports to make credit decisions

Employment Information

Gross Yearly Individual Income ($0 To $9,999,999)

Enter your total personal income (for the applicant only) from salaries, investments, rental property proceeds, Social Security benefits, and other sources. You do not need to include alimony, child support or separate maintenance income if you will not rely on those funds to repay your credit plan.

Gross Yearly Additional Income ($0 To $9,999,999)

Enter any supplemental sources of income which you have not included in the gross yearly individual income field above. Enter $0 if you do not have any additional income. Non-taxable income, if included, should be increased by 25%.

Monthly Mortgage or Rent ($0 To $9,999,999)

You consent to the LendingClub E-Sign Consent *

You understand and agree that by checking this box you are providing written instructions to ReUnite Rx and third party financing entities, including LendingClub Bank, N.A. (“LendingClub”), under the Fair Credit Reporting Act, authorizing them to obtain information from your personal credit profile or other information from one or more consumer reporting agencies to (1) check if you qualify for financing and (2) verify your identity and the information in your application. You understand that LendingClub may share information from your credit report with (1) its subsidiaries and (2) its partner banks. LendingClub may use your consumer report for any legal purpose, including authenticating your identity, making decisions related to your loan, sending follow-up loan offers, and servicing or collecting any loan that you receive. You also authorize LendingClub to verify information in your application and you agree that LendingClub may contact third parties to verify any such information. *

By checking this box, you agree to the following: LendingClub Application Terms and Conditions, LendingClub Credit Profile Authorization, LendingClub Privacy Policy, NBT Bank Privacy Policy. *

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT OR ESTABLISHING A NEW CUSTOMER RELATIONSHIP

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open an account, or when you are added to an existing account, we will ask for your name, permanent physical street address, date of birth, and other information, which may include social security number or TIN, that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. You may also be asked to provide such information at other times upon request of the Bank. We will accept a post office box only as a mailing address.

Complete the information below to see if you prequalify for financing on your fertility medications

Please note this financing offer is for use at participating clinics and ReUnite Rx pharmacies only

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT OR ESTABLISHING A NEW CUSTOMER RELATIONSHIP