Payment Plan Pre-Screen Form | NDS Dental Assistant School

Step 1 of 18

Attention: By filling out this form you are permitting NDS Dental Assistant School (also know as National Dental Services) to submit the information you are providing to our 3rd party lenders. This may or may not show on your credit report as an inquiry. If you agree click Next and answer each question.

What is your Name?

First Name(Required)

Last Name(Required)

What is your address?

Address(Required)

Street Address Address Line 2 City State ZIP Code

Please provide your Date of Birth and Social Security Number

Date Of Birth(Required)

Social Security Number(Required)

Are you a US Citizen or Permanent Resident?

US Citizen or Permanent Resident(Required)

Yes

Do you have VA benefits?

Do you have VA benefits(Required)

Yes

Have you used your military benefits to pay for school?

Have you used your military benefits to pay for school?(Required)

Yes

If a down payment is required to begin your program, how much are you able to pay upfront?

This helps us match you with the best financial plan.

If a down payment is required to begin your program, how much are you able to pay upfront?(Required)

Less than $500

$500 – $1,000

$1,000 – $2,000

$2,000 – $3,500

More than $3,500

I’m not sure yet

To help us set up a plan that works best for you, what monthly payment amount would you be able to commit to?

Proposed monthly amount(Required)

Do you want to add a strong cosigner?

Do you want to add a strong cosigner?(Required)

Yes

Cosigner's Name(Required)

First Last

Cosigner's Date of Birth(Required)

Month

Day

Year

Cosigner's SSN(Required)

Cosigner's Email(Required)

Cosigner's Phone(Required)

Cosigner's Relationship(Required)

Cosigner's Address(Required)

Street Address City State ZIP Code

Cosigner's Income(Required)

Highest level of education (some high school, high school or equivalent, some college, Associate degree, Bachelor degree, Master degree)

Highest level of education(Required)

Current employment status (NO WORRIES IF YOU’RE NOT EMPLOYED)

Are you currently employed?(Required)

Full-Time

Part-Time

Self-Employed/Freelance

Unemployed

Student

Prefer Not To Say

Employer Name(Required)

Job Title(Required)

Gender

Gender(Required)

Male

Female

Other

Prefer Not To Answer

Yearly income before taxes (Estimate)

Yearly income before taxes (Estimate)(Required)

Do you have a credit score higher that 670?

Do you have a credit score higher that 670?(Required)

Yes

Monthly Mortgage or Rent

Monthly Mortgage or Rent(Required)

What is your email address?

Email address(Required)

What is your phone number?

What is your phone number?(Required)