Financing

IMPORTANT: Please contact us first before filling out this form. You can do so multiple ways using the 'Contact Information' page. This form is meant to expedite the process of leasing one of our systems, as well as eliminating the need to print and fax this information, making it easier for our customers. Thank you!

ALL fields are required, with the exception of adding 'Comments' at the end.

Equipment

Make: *

Model: *

Quantity: *

Cost: *

Applicant/Corporate Information

Corporate Name: *

Phone Number: *

Address, Number and Street Name: *

City: *

State: *

Zip Code: *

Date Established: *

Federal ID #: *

Medical License #: *

Fiscal Year End: *

Owners/Partners

Names: *

Bank and Lease References

Bank Name: *

Contact Name: *

Address, Number and Street: *

City: *

State: *

Zip Code: *

Phone: *

Account Types and #s: *

Lease Reference (1): *

Contact: *

Address, Number and Street: *

City: *

State: *

Zip Code: *

Phone: *

Account #s: *

Lease Reference (2): *

Contact: *

Address, Number and Street: *

City: *

State: *

Zip Code: *

Phone: *

Account #s: *

Electronic Signature

By typing your electronic signature, and dating it, you submit that the information above is completely acurate and truthful. This is legally binding.

Authorized By: *

Title: *

Date: *

Comments (Optional):

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