The Future of Medical Technology Innovations © Copyrighted 2010.  All Rights Reserved.
What is the Legal Structure of the Business?* Choose One:
Sole Proprietorship Partnership LLC Corporation
PLEASE NOTE: NON-PROFIT ORGANIZATIONS ARE NOT ELIGIBLE FOR SBA LOANS
What Product or Service does the Business sell?* Be specific.
Legal Name of Business* Do you do business under a different name?
Mailing Address of Business* City* State* Zip*
Location of Business
(if different from mailing address)		 City State Zip
Average Monthly Sales Average Annual Sales (last 3 yrs) Business Telephone* Business Fax*
The sales figures above are:* Best Contact:* Other Business Contact Number Email Address:*
Actual Sales* Projected Sales
Length of time business has been operating under current ownership? Industry Experience of Principal: Business Website Federal Tax ID Number
Yrs: Mnths: Yrs: Mnths:
PRINCIPAL AND GUARANTOR #1 - Percentage Ownership: Do you have ownership in any other companies or business?
%   Yes No If yes, % owned
Last Name* First Name* Middle Name* Date of Birth
Residence Address City State Zip
Renting? Own? Residence Telephone: Social Security Number
Yrs: Mnths: Yrs: Mnths:
Driver's License Number ( State and expiration date) My Total Liquid Assets/Cash in Banks
State: Expires on:  
PRINCIPAL AND GUARANTOR #2 - Percentage Ownership (If you are only a guarantor then ownership % is 0)
%      
Last Name First Name Middle Name Date of Birth
Residence Address City State Zip
Renting? Own? Residence Telephone: Social Security Number
Yrs: Months: Yrs: Months:
Driver's License Number ( State and expiration date) My Total Liquid Assets/Cash in Banks
State: Expires on:  
 

Electronic Signature of Principal/Guarantor Date
(s// john brown)

 Date  
 

Electronic Signature of Principal/Guarantor Date
(s// john brown)

 Date  
       
     
This application submitted electronically shall have the same force and effect as if the application bore an inked original signature(s). The above information,   together with any accompanying financial statements, schedules, or other materials, is submitted for the purpose of obtaining credit and is warranted to be true,  correct and complete. The undersigned hereby warrants that any individual identified above who is either a principal, a personal guarantor or a sole proprietor   of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, has   provided his/her written authorization his/her written authorization for inquiry into their credit worthiness, including but not limited to obtaining   a consumer credit report, and shall hold eLease Funding and its assignees, agents or nominees harmless from same. You understand that such investigation may   include seeking information as to the background, credit and financial responsibility of your officers and principals (or any of them). The Federal Equal Credit   Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital   status or age (provided the applicant has the capacity to enter into the binding contract); because all or part of the applicant's income derives from any public   assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. If for any reason your   application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please   write to eLease Funding, Inc., 2820 First Avenue North, St Petersburg, FL, 33713      IT Solutions Allscripts EHR Physicians eServices EHR Stimulus Breaking News