Please complete our easy application and one of our knowledgeable Business Development Account Managers will review it and contact you right away. To submit your application, please fill out all information below.
Medical Practice Information
Contact Name
Provider (Company) Name
State or Province
City
Phone
Cell Phone
E-mail
Fax
Contact Name
Corporate Structure	Corporation LLC Partnership Sole Proprietorship
State of Incorporation
Approximate Date of Incorporation
Years in Business
What type of healthcare services do you provide?
Do you have any outstanding loans that have liens on your accounts receivable? if yes how much?

Accounts Receivable Information:
Total Receivables Outstanding (do not include Self-Pay)
What is the approximate Net Realized Value (NRV) of Total Receivables Outstanding? (Approximately)
Monthly average sales? (Approximately)
Average number of days to collect? (Approximately)
Outstanding A/Rs over 90 days? (Approximately)
By what date would you like to have a your account ready to fund?
Marketing Information:
How did you find our web site? Select Google Yahoo MSN Search engine AOL Search Business Journal AD Postcard Received BusinessFinance.com FedMarket.com Web Search Engine Magazine Ad Yellow Pages Other What keywords or phrase did you use? If other, please specify: