MediqFinancial.com     APPLICATION FORM
For immediate consideration, please complete this form online. Fill in the blanks below, and submit it directly to us by clicking on "Submit Information" at the end of the form.
Information on Business
FULL LEGAL NAME OF THE BUSINESS:

DBA:
STREET ADDRESS:
CITY:
STATE, ZIP:
FINANCIAL CONTACT:
PHONE:
NATURE OF BUSINESS:
FAX:
YEARS UNDER CURRENT OWNERSHIP:
AGE OF BUSINESS:
FEDERAL TAX ID#:
ARE YOU DUNN & BRAD RATED?
YES NO
OFFICE EMAIL ADDRESS:
ANNUAL REVENUE:
CORPORATION
PUBLICLY HELD
CLOSELY HELD
SOLE PROPRIETORSHIP
GOVERNMENT

PARTNERSHIP
GENERAL
LIMITED
NON-PROFIT

Personal Information on Borrower
NAME:
PROFESSIONAL DEGREE
PROFESSIONAL LICENSE#
IN WHAT STATE
DATE FIRST ISSUED
CURRENT HOME ADDRESS
CITY,STATE,ZIP
FORMER HOME ADDRESS
CITY,STATE,ZIP
SOCIAL SECURITY NO.
PERSONAL GUARANTEE
YES NO
TITLE
DATE OF BIRTH
DRIVER'S LICENSE NO.
% OWNERSHIP
HOME PHONE NUMBER
CELLULAR OR PAGER NO.
HOME EMAIL ADDRESS:
Amount Requested:
Transaction Type
EQUIPMENT
        SALES/LEASEBACK
NEW EQUIPMENT
        LEASE OR PURCHASE
PRACTICE ACQUISITION
SELLING YOUR
        PRACTICE
FACILITY ACQUISITION
IPA DEVELOPMENT
MSO DEVELOPMENT
MORTGAGE LOANS
LINE OF CREDIT
ACCT. RECEIVABLE
        FINANCING
EQUIPMENT REFINANCE
USED EQUIPMENT LEASE OR PURCHASE

 
Please describe use of funds:
 

Equipment Supplier (New Equipment)
NAME:
ADDRESS
CITY,STATE,ZIP
CONTACT
PHONE

Bank References
PRIMARY BANK
PHONE
OFFICER'S NAME
ACCOUNT #
ACCOUNT TYPE
PRIMARY BANK
PHONE
OFFICER'S NAME
ACCOUNT #
ACCOUNT TYPE

Trade References
CURRENT VENDOR/SUPPLIER
PHONE
CONTACT
ACCOUNT #
CURRENT VENDOR/SUPPLIER
PHONE
CONTACT
ACCOUNT #
CURRENT VENDOR/SUPPLIER
PHONE
CONTACT
ACCOUNT #
How were you referred to MediqFinancial?

For purpose of securing financing, I, the undersigned, affirm that the information I have provided is true and accurate. I authorize and instruct MediqFinancial.com, its assignees, any person, consumer reporting agency or bank institution to compile and furnish information to be released via telephone, email or facsimile transmission utilizing the information provided on this credit application. A fax, photocopy or email of this authorization shall be valid as the original.

Title
Your Name
Your Signature
Date
Initials Date       (initials will be used as electronic acceptance of the aforementioned terms of this form.)


In consideration of this application, regardless of the type of loan you wish to pursue, it is very helpful for us to review a list of the office or professional equipment that you lease or own. Equipment can be a valuable source of collateral.
Check here if you do not own any equipment, or do not wish to refinance an equipment lease or loan or do not wish to apply to lease new or used equipment. If you check here, please submit your application without completing the "List of Equipment" that follows. You can find the "Submit" button at the bottom of the equipment list.
Please indicate which items below apply, and complete the form noted below, "List of Equipment":

I wish to borrow against equipment that I own free and clear and that I am specifying on the form below. I attest and certify that I own this equipment and that it is free of all liens and encumbrances.

I wish to refinance debt (leases or loans) that is currently against the equipment that I am specifying on the form below.

I wish to lease new or used equipment that I am specifying on the form noted below.


If you choose to print this form, please be advised that it may take several minutes before your printer starts printing.



  LIST OF EQUIPMENT
Complete this form, submit it and submit as many more pages as you need.
Page of

Business Name:
Business Address:
Business Phone #:
Year Manufacturer Item Model No. Serial No. Est. Value New

_______________________________________       _____________________
Signature                                                                         Date
Initials Date   (initials will be used as electronic acceptance of the aforementioned terms of this form.)



         


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