By completing the credit application form and submitting it, I acknowledge that the application information provided is true and correct to the best of my knowledge.  I also acknowledge that I have received proper authorization by the co-applicant to include the co-applicant's information on this application.  I agree to give Health One Financial and / or their lending companies, including, but not limited to, Banks, Finance Partners, Credit Card Issuers and other types of companies, written authorization to access my credit profile for review purposes.

For consideration of the Health One Card, I understand that Elan Financial Services, as a creditor and issuer will rely on the information provided here in making its credit decision, and certify that such information is accurate and complete to the best of your knowledge.  If Issuer opens an account based on this application, you will be individually liable if this is an individual account or individually and jointly accountable if this is a joint account for all authorized charges and for all fees referred to in the most recent Cardmember Agreement, which may be amended from time to time.  You authorize Issuer, in determining your eligibility for credit, to verify your employment and income and all other information that you have provided, and obtain information about yourself, including your residence address, from other creditors, credit bureaus, employers, third parties, and federal and state records, including any state motor vehicle department, and waive any rights of confidentiality you hay have in that information under applicable to law.

By selecting "SUBMIT", you authorize Issuer to provide Health One Financial with your credit decision and notify Health One Financial when you activate your card for the limited purpose of performing provider services.  You also certify that you have read and understood both the disclosures and terms & conditions here and agree to the terms of this application. You understand that that you will be assessed a one time Program Fee of $49 or $4% of the procedure up to a maximum of $149, payable to Health One Financial for securing your financing.  You understand this Program Fee will be billed to your Health One Account once your Health One Card has been activated. No additional fees will be charged for future expenditures against your Health One account.