Type
of Business:
Professional
Corporation
Medical Corporation
Proprietorship
Sole
Proprietorship
LLC
Business
Address
Business
Telephone
Fax
Home
Address
Home
Telephone
Social
Security Number
Date
of Birth
DD
MM
YY
Project
Type: (check
all that apply)
Cash Only
Amount
Needed:
New Equipment
Amount
Needed:
Sales/Leaseback
Amount
Needed:
Leasehold/Capital Improvements
Amount
Needed:
Other (Specify) :
Amount
Needed:
Total Amount Requested
By
signing below, each undersigned individual(s), who is either
a principal of the credit applicant listed above or a personal
guarantor of its obligations, provides written instruction
to Lender or its Assignee, and certifies that all information
provided is true and correct, and authorizes Lender or its
assignee(s) to verify any credit information from whatever
source it deems necessary and further authorizes Lender or
its assignee(s) to investigate the references, statements
or other data listed or accompanying this application . The
undersigned authorizes all parties contacted including but
not limited to any credit reporting agency to release credit
and financial information requested by telephone or facsimile.
The undersigned further acknowledges and agrees that they
will notify the Lender in writing of any change in name, address
or employment within a reasonable time thereafter. The undersigned
further understands that any information obtained now or from
time to time will be treated confidentially and will only
be used for securing financing or for the purposes of updating,
renewing or extension of such credit or additional credit
and for reviewing or collecting the resulting account. A Photostat
or facsimile copy of this authorization shall be as valid
as the original. By signature below, I/we affirm my/our identity
as the respective individual(s) identified in the above application.
The
undersigned further acknowledges that if they are approved
based on the information provided on this application, bank
and trade references may be required.
