Corporate Office: 711 W. 17th Ste #J5, Costa Mesa, CA 92627

New York Office: 45, Oriole Way Dix Hills, NY 11746

Phone Number: (888) 277-6633

General Financing Application

First Name *

Last Name *

Social Security Number *

Tax ID #

Date of Birth *

Home Address *

State *

City *

Postal Code *

Email *

Mobile Phone *

FICO Score

Us Citizen *

Own Residence *

Current Practice Information

Specialty *

Subspecialty

Practice Name

Work Number

Website

Practice Address

Practice State *

Practice Zip Code

Practice City

Location Status

Gross Annual Revenues *

Monthly Payment *

Business Entity *

Business Start Date *

Medical License #

Medical License Start Date

Are there multiple Owners?

If yes to multiple owners and they own 20% or more please fill out below.

%Owned By You

Co-Owner Email

Co-Owner First Name

Co-Owner Last Name

We will send them a co-ownership application to fill and sign. Required for Loan. Please let your partner know to expect an email application from ProMed Financial, Inc.

Requested Loan Type

Loan Type *

Loan Amount *

Description of Amount *

Other Information

Any Existing lien On Practice/Equipment Leases

Are you Currently Liable For Delinquent taxes?

Have you ever Filed Bankruptcy ?

Applicant involved in any litigation? If YES, explain here.

If you own any other Practices, please list name(s) below.

Terms and Conditions

Applicant warrants all credit and financial information submitted to ProMed Financial Inc. and/or its assignees to be true and accurate and hereby authorises all banking institutions and credit reporting agencies to release necessary information via telephone, email, internet or facsimile required for purpose of making a credit decision. The undersigned individual(s) specifically authorizes ProMed and/or its assigns to obtain personal credit bureau reports for the making, extension, or renewal of this credit decision or collections of the resulting account.

By checking this box you agree to receive automated Promotional and transactional messages from ProMed Financial, Inc. You may receive up to 3 msgs/wk. Message and Data Rates May Apply. You may type Stop to opt out at anytime. Text Help for help.

I agree to Terms & Conditions/ Privacy Policy provided by the company. By providing my phone number, I agree to receive text messages from the business.

Applicant’s Signature *

Clear

Draw Signature into Box.