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Funds Needed:    *
Where did you hear about us:
Today's Date:
What is the purposed use of the funds: *
Legal Name Of The Business / Practice: *
Federal Tax ID #:  -  *
Time in Business: Year(s)*
E-mail Address: *
Practice Address: *
City: *
State: *
Zip Code: *
Type of Business / Practice Structure: *
Business Owner Name: *
Title: *
Percentage of Ownership: *
Social Security #: *
Date of Birth: *
Home Address: *
City:   *
State: *
Zip Code:
Home Phone #: *
Business Phone #: *
Business Fax #:
Other Phone #:
Does your business accept MasterCard/Visa? : YES NO
If yes, what are your average monthly charges?: $
Business Annual Gross Income : *
Annual Personal Income: *
Net Worth:
Medical Related License #: *
Date first Licensed:

By initialing the this loan application I hereby authorize the release of all credit information, including loans, leases, checking, savings, trade references and personal credit history, pertaining to the company, its principles, and the people listed below to Bankers Healthcare Group, Inc. and/or its designees or assignees. Such authorization shall extend to subsequent updates for credit and collection purposes.

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