Request for a Practice Financing Quote

Name of Practice *

Address *

City *

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Columbia (District of) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming*

Zip Code *

Email Address *

Phone Number *

Fax number

Cell Phone Number

Contact Person *

Position of Contact Person
Owner, Accountant, etc.

How Long has Your Practice Been Operating? Less than one year 1-5 years 6-10 years Greater than ten years*

Type of Financing Requested Working Capital Practice Acquisition Equipment Financing Real estate purchase Tenant Improvements Practice Refinancing Debt Consolidation Combination of the above *

Amount of Financing Requested Less than $25,000 $25001 to $49,999 $50,000 to $74,999 $75,000 to $99,999 $100,000 to $299,999 $300,000 to $499,999 $500,000 to $1,000,000 Greater than $1,000,000 *

What is your approximate credit score?
This is to help us make a preliminary assessment of your request. We will have to run a credit report to determine final terms. not sure less than 600 600 to 624 625 to 649 650 to 674 675 to 699 700 to 749 greater than 750

When is the best time to contact you? Morning Afternoon Evening*

Please describe your practice, clinic, or hospital *

Describe the purpose of the financing
i.e., the type of equipment to be purchased or how the proceeds of the financing will be used. *

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