ࡱ> bda5@ EUbjbj22 "XXX "8>L"]&<J8888%%%%%%%$'R)%9&&&%88&&888%&%H""8> `x4<"\"\-&0]&"*RX*"*"HhTe%%"""""Rochester Equipment Leasing, Inc. E-mail: info@e1lease.com 36 West Main St. Suite 777 www.e1Lease.com 1-800-388-3430 ext 302 Rochester, NY 14614 1-877-617-1561 (fax) CREDIT APPLICATIONDATEAMOUNT REQUESTED $  MONTHS REQUESTED 60 mos.  FORMCHECKBOX  72 mos.  FORMCHECKBOX   FIRST 3 MOS. @ $100 Yes  FORMCHECKBOX  NO  FORMCHECKBOX Business Structure  FORMCHECKBOX  Sole Proprietorship  FORMCHECKBOX  Partnership  FORMCHECKBOX  PLLC  FORMCHECKBOX  LLC  FORMCHECKBOX  Corporation  FORMCHECKBOX  Other _________________ State of Inc. _____ Date of Inc.  FORMTEXT      Purpose/use of funds:Date funds needed:EXACT LEGAL NAMECONTACT NAME Best time /day to contact: TIME: DAY:DOING BUSINESS AS: (TRADE NAME)PRIMARY LOCATION MAILING/ BUSINESS ADDRESS STREET: CITY/ STATE/ ZIP: BUSINESS PHONE NUMBER: BUSINESS FAX NUMBER:SECOND LOCATION MAILING/ BUSINESS ADDRESS STREET: CITY/ STATE/ ZIP: BUSINESS PHONE NUMBER: BUSINESS FAX NUMBER:Type of Medical PracticeTime in business (TIB)Date License IssuedLicense NumberState LicensedDescribe your professional experience for the past four (4) years: (What field practiced in, where and for how long?)Describe your capital resources and amounts you personally invested if this practice is new or acquired within the past one (1) year. PRINCIPAL / OFFICER / PARTNER NAMESOCIAL SECURITY #TITLE AND % OWNEDHOME ADDRESS US CITIZEN Yes  FORMCHECKBOX  NO  FORMCHECKBOX OWN HOME Yes  FORMCHECKBOX  NO  FORMCHECKBOX # YEARS AT CURRENT ADDRESS: HOME TELEPHONE NUMBERUSE SECOND PAGE IF MORE THAN ONE DOCTOR IN PRACTICE FULL SPOUSE NAME (REQUIRED)SOCIAL SECURITY% PRACTICE SPOUSE OWNED SIGNER AT PRACTICE BANK  Yes  FORMCHECKBOX  NO  FORMCHECKBOX  PRACTICE SPACE OWN  FORMCHECKBOX  RENT  FORMCHECKBOX TIME IN SPACE YEARS: MONTHS:MONTHLY PAYMENT AMOUNT $ PROPERTY INSURANCE COMPANYPRACTICE BANK ACCOUNTACCOUNT #TELEPHONE #OFFICER TO CONTACTBANK NAME  AUTHORIZATION TO OBTAIN CREDIT INFORMATION Applicant warrants all credit and financial information submitted to Rochester Equipment Leasing (here after referred to as REL) and/or its assignees to be true and accurate and hereby authorizes all banking institutions and credit reporting agencies to release necessary information via telephone, mail, Internet or facsimile as requested for purposes of making a credit decision. The undersigned individuals*5;BIM  # f g z     - 4 5 ߼NJ{oh0yCJOJQJ^Jh0y5CJOJQJ\^J h0yCJ h0yCJh0y5OJQJ h0yCJ$h0yh0yCJ^Jh@Rh@RCJ^Jh@Rh0yCJ^J h0yCJ h pDCJ h@RCJ h0yCJ h0yCJ hvGCJ h@RCJ h@RCJ h@Rh@RCJ #g    - e 0*0*s0*0*g*njwh v:wh wh ^qh Vw^qV$If $d$Ifa$ d$If^kd$$IflP*?+0?+4 la$If  !  ! AUBUDU5 6 D E F P R S a b c d e ٰ}yjaI/jhh0y5CJOJQJU\^JaJh0y5CJ\h0y5CJOJQJ\^Jh0y h0yCJ/jh0y5CJOJQJU\^JaJ)jh0y5CJOJQJU\^JaJ h0y5CJOJQJ\^JaJ/jh0y5CJOJQJU\^JaJ h0y5CJOJQJ\^JaJ)jh0y5CJOJQJU\^JaJ       ! & ' 5 6 7 9 < ȹtbP#jh0y5CJU\aJ#j8h0y5CJU\aJ#jh0y5CJU\aJh0y5CJ\aJh0y5CJ\aJ#jPh0y5CJU\aJh0y5CJ\aJjh0y5CJU\aJ h0yCJh0y)jh0y5CJOJQJU\^JaJ/jh0y5CJOJQJU\^JaJ  & > ] v   1s1j1j1j1j1j1j1j1j]Ykd$$Ifl4r,l#*F@ @ p` ?+4 laf4 d$If $If$If < = > ? 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A fax or photocopy of this authorization shall be valid as the original. 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