Pre-Approval Credit Application
Print application, answer questions and fax to Innovative Healthcare
Phone: (800) 526-5557 Fax: (561) 793-5311
richgant@innovativehealthcare-llc.com
Company/Practice Information
| LEGAL BUSINESS NAME: | SPECIALTY: |
| BUSINESS ADDRESSES: | COUNTY: |
| CITY/STATE/ZIP | |
| PHONE: | FAX: |
| EMAIL: | CELL: |
| YEARS IN PRACTICE: | TAX ID: |
| EQUIPMENT: | PRICE: |
Personal Information
| NAME: | TITLE: | OWNERSHIP%: |
| HOME ADDRESSES: | CITY: | STATE/ZIP: |
| CITY/STATE/ZIP | ||
| HOME PHONE: | CELL: | |
| SOCIAL SECURITY#: | PROFESSIONAL LICENSE#: | |
| DATE OF BIRTH: | ANNUAL INCOME: | |
| DO YOU HAVE A: | CHECKING ACCT: YES ___ NO ___ | SAVINGS ACCT:YES ___ NO ___ |
| DO YOU: | OWN YOUR HOME: YES ___ NO ___ | RENT YOUR HOME:YES ___ NO ___ |
Partner Information
| NAME: | TITLE: | OWNERSHIP%: |
| HOME ADDRESSES: | CITY: | STATE/ZIP: |
| CITY/STATE/ZIP | ||
| HOME PHONE: | CELL: | |
| SOCIAL SECURITY#: | PROFESSIONAL LICENSE#: | |
| DATE OF BIRTH: | ANNUAL INCOME: | |
| DO YOU HAVE A: | CHECKING ACCT: YES ___ NO ___ | SAVINGS ACCT:YES ___ NO ___ |
| DO YOU: | OWN YOUR HOME: YES ___ NO ___ | RENT YOUR HOME:YES ___ NO ___ |
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Signature |
Date |
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Signature |
Date |
By signing this application I/we hereby authorize the release of business and/or personal credit information to Innovative Healthcare, LLC and/or its assigns for the purpose of investigating my/our credit for the purposes of obtaining lease financing. I/we certify that the information given herein is true and correct. A photo static and/or facsimile copy of this authorization shall be valid as the original. To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.