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

    Equipment Description

    Equipment Description

    Vendor

    Vendor

    Manufacturer/Model

    Manufacturer/Model

    Installaition date

    Installaition date

    Is pre-funding mandatory?

    Is pre-funding mandatory?

    Amount

    Amount

    Equipment Description

    Equipment Description

    Vendor

    Vendor

    Manufacturer/Model

    Manufacturer/Model

    Installaition date

    Installaition date

    Is pre-funding mandatory?

    Is pre-funding mandatory?

    Amount

    Amount

    Are you or any borrowers, owners, or guarantors related to or closely associated with a Politically Exposed Person (PEP)?

    Are you and all of the borrowers, owners, or guarantors U.S. Citizens or Permanent Residents?

    By signing below, each representative of the Applicant declares that he/she has read and understands the statement above.

    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.