Skip to form
Loan Program Application
First Name
*
Last Name
*
Company Name
*
Shipping Address
*
State/Region
City
Postal Code
*
Country
*
Please Select
Canada
United States
Phone Number
*
Email
*
Mobile phone number
Duration of Loan
*
2 Weeks
4 Weeks
I am interested in tecla for:
*
Please Select
A Student
A Patient
A Client
How did you hear about The Tecla Loan Program?
Please Select
Tecla Website
Social Media
Resource Centre Referral
Tecla Representative
Other
Additional Info
Tecla is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:
I agree to receive other communications from Tecla.
You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy.
By clicking submit below, you consent to allow Tecla to store and process the personal information submitted above to provide you the content requested.
Submit