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Medical Credit Application
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Customer Information
Business Legal Name
DBA
(If applicable)
Phone #
Contact First Name
Contact Last Name
Title
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Chief Executive Officer
Chief Financial Officer
Chief Information Officer
Chief Operations Officer
Chief Technology Officer
Controller
Director
Executive Director
General Partner
Manager
Managing Member
Member
Owner
Partner
President
Secretary
Sr. Vice President
Treasurer
Trustee
Vice President
Cell #
Email
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Business Street Address
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ZIP
City
State
Federal Tax ID
Date Business Started Under Current Ownership
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# of Workers
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Industry Type
Auto Aftermarket
Beauty Salon, Spa
Bowling Center
Car Wash - Stand Alone
Child Care
Chiropractor
Construction
Dentist, Orthodontist
Education
Equipment Rental / Sales
Fitness
Full-Service Restaurants
Gasoline Stations
General Rental Centers
Grocery and Convenience Stores
Healthcare
Hotel and Motels
Laboratories
Landscape
Manufacturing
Meat Markets
Mining, Quarrying, and Oil and Gas Extraction
Misc Retail
Other Grocery and Related Products Merchant Wholesalers
Physician
Printing
Professional Services
Restaurant - Franchise
Technology Support, Telecomm, Software
Trucking Local Haul
Trucking Long Haul
Veterinary
Gross Annual Revenue in Prior Fiscal Year
$
You entered revenue equal to or greater than $50 million. Please re-enter if not correct.
Finance Amount
Website
Legal Structure
Sole Prop
Partnership
LLC
Corporation
Business Owners or Officers
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First Name
Last Name
JR.
SR.
I
II
III
IV
V
Suffix
Choose One
Chief Executive Officer
Chief Financial Officer
Chief Information Officer
Chief Operations Officer
Chief Technology Officer
Controller
Director
Executive Director
General Partner
Manager
Managing Member
Member
Owner
Partner
President
Secretary
Sr. Vice President
Treasurer
Trustee
Vice President
Title
Email
Email address is required
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Cell #
% Ownership
% Ownership is required
Social Security #
Social Security # is required
Home Address
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Address is required
ZIP
Zip Code is required
City
State
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