Medical Health Industry Loan

Medical Health Industry Capital Application

This form is also available as a download which can be faxed to 336-217-8155.
Word	PDF	RTF

Grow Your Business or Medical Practice

Meet Payroll

Pay Taxes

Meet Seasonal Demands

Amount of Loan:
Purposed Use of Funds:
Business Name:
Phone:
Fax:
Address:
State:
Zip Code:
E-mail Address:
Type of Business:
Business Type:
Years in Business:
Tax I. D. #:
Principal's Name:
Title:
SSN:
Home Address:
State:
Zip Code:
Phone:
Principal's Name:
Title:
SSN:
Home Address:
State:
Zip Code:
Phone:

If Physician, Dentist, Veterinarian or Chiropractor, please fill out the following:
Year Licensed:
State:
License#:

Date Registered:
Bank:
Account #:
Account Type:
Contact:
Phone:
Fax:
(List Previous Bank if At Present Bank Less Than 2 Years)
Bank:
Account #:
Account Type:
Contact:
Phone:
Fax:
Check your funding interest(s):
Debt Restructuring Settlement Financing SBA Express Loans Purchase Order Funding Equipment Financing Consolidation Loan Commercial Mortgage Accts. Receivable Factoring
Additional Comments:
I authorize you to obtain such information as you may require concerning the statements contained in this application, and agree that the application shall remain your property, whether or not the lease is granted. I hereby certify that all statements contained in this application are true and complete and are made for the purpose of obtaining credit. I agree to notify you of any material changes in the condition of affairs, and this statement shall be construed by you to be a continuing statement of the conditions of the Lessee until written notice to the contrary is received by you. Lessee and its principal authorize the release of credit information to the Lessor.
By: Title: Date: