HEALTHCARE CREDIT APPLICATION

    HEALTHCARE CREDIT APPLICATION














    PRIMARY BUSINESS ADDRESS































    Credit Authorization

    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.