Firmco Medical Application COMPANY INFORMATION ( PLEASE COMPLETE APPLICATION IN FULL, THEN SIGN AND DATE ) USE BACK IF NECESSARYLegal Company NameDBAPhoneFaxBilling AddressCityCountyStateZipEquipment location(blank if same)CityCountyStateZipType of BusinessYears in BusinessEmailFederal ID No.State of OrganizationSelectCorporationPartnershipProprietorshipLLCPrincipal/Partner/OfficerHome Phone #Accounts Payable ContactPhoneAddress% OwnedRespiratory ContactPhone #City/State/ZipSoc. Sec #Purchasing ContactPhone #Phone #Exempt #(if applicable)TaxableExempt**If exempt, attach copy of Tax Exempt Certificate**Upload fileChoose FileNo file chosenDelete uploaded fileBank ReferencesBankContact PersonAccount #Phone #BankContact PersonAccount #Phone #BankBankTrade ReferencesSupplierContact PersonAccount #Phone #SupplierContact PersonAccount #Phone #Are any assets now assigned, pledged, or liened as collateral for loans?Accounts ReceivableYesNoIf so to whom?InventoryYesNoIf so to whom?EquipmentYesNoIf so to whom?For the purpose of securing lease/equipment financing, I authorize Firmco Medical, Inc., it’s nominees or assigns, to do a complete credit check using the information provided above or attached, including the review of personal credit reports on the principal(s) or guarantor(s) of the credit applicant. I authorize all deposit and credit information to be released by telephone or fax. A Photostat or facsimile copy of this authorization shall be valid as the original. SIGNATURESIGNATURETitleDateSubmit Application
