Equipment Loan Application Company Information Legal Business Name TIN Address Years in business Phone Legal Structure Website Nature of Business Existing Debt of Practice Speciality Last year annual revenue: Year to date revenue -What month is that through Principal Information Principal Information Name/title Name/title Ownership % Ownership % Address Address Phone Phone Email Email SSN SSN Date of Birth Date of Birth Principal Information Principal Information Name/title Name/title Ownership % Ownership % Address Address Phone Phone Email Email SSN SSN Date of Birth Date of Birth Equipment Loan Request Information Finance amount Term in months 36486084120 Equipment Description Equipment Description Vendor Vendor Manufacturer/Model Manufacturer/Model Installaition date Installaition date Is pre-funding mandatory? YesNo Is pre-funding mandatory? YesNo Amount Amount Equipment Description Equipment Description Vendor Vendor Manufacturer/Model Manufacturer/Model Installaition date Installaition date Is pre-funding mandatory? YesNo Is pre-funding mandatory? YesNo Amount Amount Are you or any borrowers, owners, or guarantors related to or closely associated with a Politically Exposed Person (PEP)? YesNo Are you and all of the borrowers, owners, or guarantors U.S. Citizens or Permanent Residents? YesNo By signing below, each representative of the Applicant declares that he/she has read and understands the statement above. Clear This information and the information provided on all accompanying financial statements and schedules is provided for the purpose of obtaining credit for the Applicant(s) or for the purpose of Applicant(s) guaranteeing credit for others. Applicant(s) acknowledge that representations made in this Statement will be relied on by Creditor in its decision to grant such credit. This Statement is true and correct in every detail, and accurately represents the financial condition of the Applicant(s) on the date given below. You are authorized to make all inquires you deem necessary to verify the accuracy of the information contained herein and to determine the creditworthiness of the undersigned. Applicant(s) will promptly notify Creditor of any subsequent changes which would affect the accuracy of this Statement. Creditor is further authorized to answer any questions about Creditor’s credit experience with Applicant(s). Applicant(s) are aware that any knowing or willful false statements regarding the value of the above property for purposes of influencing the actions of Creditor can be a violation of federal law 18 U.S.C. sec. 1014 and may result in a fine or imprisonment or both. The term PEP refers to foreign individuals who are or have been entrusted with a prominent public function, as well as to their immediate family members and close associates. Δ