Application form

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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