Cornerstone Medical & Technology Finance

CREDIT APPLICATION
CORNERSTONE MEDICAL FINANCE
31 SCHOOSETT STREET SUITE 205A	PHONE: (781) 829-0400
PEMBROKE, MA 02359	FAX TO: (781) 829-0415
Medical Application
CUSTOMER INFORMATION

Customer (Full EXACT Legal Name)

Phone Number

Fax Number

Fed Tax ID

DBA

Contact

Years in business

Type of Business

Headquarters Address

City

State

Zip Code

Equipment Address (if different)

City

State

Zip Code

Check One

"S" Corporation

Corporation

Not for Profit

Limited Partnership

General Partnership

Limited Liability Co.

Limited Liability Partnership

Other

Date of formation

State of formation (domestic State)

BANK INFORMATION (Should be at least 2 years old; if less, please supply previous bank reference)

Bank Name

Contact Name

Phone Number

Fax Number

Account Type

Account Number

Year Opened

Trade References

Company Name

Contact Name

Phone Number

Fax Number

Number of Years

Vendor

Contact Name

Phone Number

Cost: $

Equipment Description

Term (Please Mark):

AUTHORIZATION FOR DISCLOSURE OF PERSONAL CREDIT INFORMATION:

The following authorization(s) shall apply to this application and subsequently for the purposes of update, renewal or extension of such credit and for reviewing or collecting the resulting account. A photo static or facsimile copy of this authorization shall be valid as the original.
By signing below, the undersigned individual who is either a principal of the credit applicant or a personal guarantor of its obligations, provides written instruction to CORNERSTONE MEDICAL & TECHNOLOGY FINANCE, LLC, or its designee (and any assignee or potential assignee thereof) authorizing review of his/her personal credit profile from a national credit bureau.

Officers Name

Title

% of Ownership

Date

Signature

SSN

Home Phone Number

Home Address

City

State

Zip Code

The Federal Equal Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a 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. The federal agency that administers compliance with this law is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580.
If your application for business credit is denied or conditionally approved, you have the right to a written statement of the specific reasons for the denial or conditional approval. To obtain the statement, please contact CREDIT OPERATIONS, CORNERSTONE Medical & TECHNOLOGY FINANCE, LLC, 31 SCHOOSETT STREET, PEMBROKE, MA within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement.