Applicant Name *

First Name

Last Name

Employer Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer Phone *

(###)

###

####

Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name on the card *

List as its listed on card

First Name

Last Name

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone *

(###)

###

####

I authorize D & E Solutions Group to help find a financial solution and to charge my debit card 10% of the total amount approved. I understand that this is separate from any other fees/cost and I will not dispute or do a chargeback. If a dispute or chargeback is done, I have been informed that a copy of this signed agreement will be sent to my bank as well as any legal entity needed to collect funds owed to D & E Solutions Group. I agree to pay any and all legal fees accumulated by D & E Solutions Group in an effort to collect funds owed to them by me. *

Please E-sign your First and Last Name

First Name

Last Name

Date Signed *

MM

DD

YYYY

*

I understand that this form is a legally binding agreement between myself D & E Solutions Group.

I have read through and agree to all statements, terms and conditions stated on this form.

All of the information is accurate and truthful.