medical practice expansion loan, doctor, dentist financing

Medical & Dental Working Capital

For medical working capital, we serve all medical, dental, veterinarian, optician, chiropractor, and physical therapist professionals.

info@imsfinancial.net
toll-free P 800.650.5611 F 866.352.6058

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Customer Information
CUSTOMER / BUSINESS NAME:
FED TAX I.D. NO.:
SIC CODE:
MAILING ADDRESS – IF P.O. BOX, PLEASE LIST THE COMPLETE PHYSICAL ADDRESS BELOW
ADDRESS:
CITY:
COUNTY:
STATE:
ZIP CODE:
PHYSICAL ADDRESS – IF DIFFERENT FROM ABOVE
ADDRESS:
CITY:
STATE:
ZIP CODE:
BIRTH DATE OR INCORPORATION DATE:
YEARS IN BUSINESS:
WORK PHONE:
FAX:

Vendor Information & Equipment Description
COMPANY NAME
ADDRESS:
CITY:
STATE:
ZIP:
CONTACT / PHONE NO.:
EQUIPMENT DESCRIPTION:
QUANTITY:
MODEL:
SERIAL NO.:
PURCHASE PRICE:
INSTALLATION LOCATION:

Personal Information on Officers, Partners, or Owners
FIRST NAME:
LAST NAME:
DATE OF BIRTH:
HOME ADDRESS:
CITY:
STATE:
ZIP:
TELEPHONE:
EMAIL:
SOCIAL SECURITY NO.:
% OWNERSHIP:
DRIVER’S LICENSE:
ISSUE DATE:
EXPIRATION DATE:

FIRST NAME:
LAST NAME:
DATE OF BIRTH:
HOME ADDRESS:
CITY:
STATE:
ZIP:
TELEPHONE:
EMAIL:
SOCIAL SECURITY NO.:
% OWNERSHIP:
DRIVER’S LICENSE:
ISSUE DATE:
EXPIRATION DATE:

Business Information
TYPE OF BUSINESS (OR APPLYING AS):	AN INDIVIDUAL OR SOLE PROPRIETORSHIP
	CORPORATION
	LIMITED PARTNERSHIP
STATE OF INCORPORATION:
BANK NAME:
BANK ADDRESS:
BANK CITY:
BANK STATE:
BANK ZIP:
ACCOUNT NUMBER:
TELEPHONE NUMBER:
CONTACT:

BANK NAME:
BANK ADDRESS:
BANK CITY:
BANK STATE:
BANK ZIP:
ACCOUNT NUMBER:
TELEPHONE NUMBER:
CONTACT:

Equipment Loan Financing Leasing Co.
NAME:
ADDRESS:
CITY:
STATE:
ZIP:
ACCOUNT NUMBER:
TELEPHONE NUMBER:
CONTACT:

Trade References
NAME:
ADDRESS:
CITY:
STATE:
ZIP:

Requested Lease Terms
AMOUNT REQUESTED:
NO. OF MONTHS: