*Principal Name: *Address: *City, State, Zip: .. - AL AR AZ CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV Phone: Fax: Email Address: Contact Person: *Description of Product: *Amount Requested: Term in Months: Purchase Options: $1 10% No * indicates a required entry By clicking the "SUBMIT" button, the applicant hereby authorizes Clarion Financial, or its agents to investigate my/our credit worthiness. I further authorize release of any credit or financial information to Clarion Financial or its assignees. I represent and warrant that the information submitted herein is true and correct. If your application for credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact Clarion Financial, 370 N. Pennsylvania Ave. Wilkes-Barre, PA. 18702 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 of receiving your request for the statement. 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 applicant has the capacity to enter in a binding contract), because all or 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 this credit is the Comptroller of the Currency Customer Assistance Unit, 1301 McKinney Av, Suite 3710, Houston TX 77010. Copyright © 2009 Clarion Financial. All rights reserved.