HEALTHCARE CREDIT APPLICATION DATE AMOUNT REQUESTED $ TERM REQUESTED CIRCLE 60 Mos.72 Mos.84 Mos. EMAIL ADDRESS PURPOSE/USE OF FUNDS DATE FUNDS NEEDED EXACT LEGAL NAME CONTACT NAME: DOING BUSINESS AS: (TRADE NAME) CONTACT-BEST TIME 9 AM10 AM11 AM12 AM1 PM2 PM3 PM4 PM5 PM CONTACT-BEST day MondayTuesdayWednesdayThursdayFridaySaturdaySunday CELL PHONE# Business Structure Two years company financial statements, if statements are not audited or reviewed provide Last two years corporate tax returns including all schedulesCurrent company Interim financial statement (Not older than 90 days)Personal Financial Statement (Not older than 90 days)Last two years personal tax returns (including all schedules)Current Accounts Receivable aging report Current Accounts Payable aging reportCopy of Licenses (MJB only)Business planCompany debt scheduleAny relevant press releases, press coverage, or product literature that might help Americus Credit familiarize itself with products and/or services offered by your company.Invoice(s) of equipment that you’re purchasing State of Inc. AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingDistrict of ColumbiaPuerto RicoGuamAmerican SamoaU.S. Virgin IslandsNorthern Mariana Islands Date of Inc. PRIMARY BUSINESS ADDRESS Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe *State/Province Select State City Select City Street Postal Code / Zip BUSINESS PHONE NUMBER: BUSINESS FAX NUMBER: Fax: Business Website TYPE OF MEDICAL PRACTICE TIME OWNING THIS PRACTICE (TIB) DATE LICENSE ISSUED LICENSE NUMBER STATE LICENSED PRINCIPAL / OFFICER / PARTNER SOCIAL SECURITY # TITLE / % OWNED US CITIZEN yesno OWN HOME yesno [group group-481] # YEARS AT CURRENT ADDRESS: HOME ADDRESS HOME TELEPHONE NUMBER [/group] SPOUSE-IF ACTIVE IN PRACTICE yesno [group group-1378] SOCIAL SECURITY# % PRACTICE SPOUSE OWNS [/group] SIGNOR AT PRACTICE BANK yesno PRACTICE SPACE yesno TIME IN OFFICE SPACE YEARS TIME IN OFFICE SPACE MONTHS MONTHLY PAYMENT AMOUNT $ FEDERAL TAX ID #: PRACTICE BANK ACCOUNT ACCOUNT # TELEPHONE # OFFICER TO CONTACT BANK NAME Credit Authorization I authorize I hereby certify that the information contained in this credit application is true and accurate and I hereby authorize ACG, its partners, and lenders to obtain consumer credit reports relating to individual credit history and/or creditworthiness and any other information regarding Commercial Applicant and its owners and principals from third parties to verify any information provided on the Application. I hereby authorize the filing and recording of UCC financing statements showing the Lender’s interest in all the business assets and grant ACG the right to execute them in our company name or by the representative. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for update, renewal, or extension of such credit or additional credit and for reviewing or collecting the resulting account. I/we affirm my/our identity as the respective individual(s) identified in this application.
