Medical Equipment Financing Application

Please fill out the following application and click the "Apply Now" button at the bottom of this page. Your personal information is confidential and will be treated as such.

fields are required

Applicant Information
Legal Company Name
Address
City
State	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
Zip Code
Phone Number
Federal Tax I.D. Number
Contact Person
E-mail Address
Type of Business	Corporation   Proprietorship   Partnership
State of Incorporation	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
Number of years in Business    under Current Ownership
Number of Employees
Description of Business	( Brief description up to 250 characters. )
Billing Address (If different from above)
City
State	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
Zip Code
Lease Information
Description of Equipment Wanted	( Brief description up to 250 characters. )
Equipment Cost
Lease Term	Select a Term 12 months 24 months 36 months 48 months 60 months
Purchase Option	FMV   10%   $1.00
Personal Data
Name of Primary Business Owner
Title
Address
City
State	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
Zip Code
Social Security Number
Date of Birth	(ex. mm/dd/yyyy)
Ownership Percentage
Second Applicant Information
Name of Second Business Owner
Title
Address
City
State	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
Zip Code
Social Security Number
Date of Birth	(ex. mm/dd/yyyy)
Ownership Percentage
Reference Data
List Current Bank(s) - Previous bank info required if applicant has been at present bank less than two years
Current Bank of Applicant
Branch
Current Bank Phone
Name of Bank Officer
Account Number
Previous Bank of Applicant
Branch
Previous Bank Phone
Name of Bank Officer
Account Number
Vendor Information
Vendor Name
Contact Person
Address
City
State	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin
Zip
Phone Number
E-mail Address