Apply For Business Funding

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Business Information
Legal Business Name*
DBA Name
Address*
Street Address Address Line 2 City State ZIP Code
Business Phone*
Business Fax
Email Address
Owned Business Since*
Business Open Date
# of Locations
Briefly Describe Business

Financial Information
Average Monthly Sales*
Volume from Electronic Payments (CCs, Insurance, etc.)
Estimated Total Monthly Sales
Requested Financing Amount*
Federal Tax ID*
Is your business for sale?*
- Yes
- No
Do you have Federal or State Tax Liens?*
- Yes
- No
If yes, please explain
Do you have any Outstanding Financing?*
- Yes
- No
If yes, please explain
Have you ever filed for Bankruptcy?*
- Yes
- No
If yes, include dates and explanation
Intended Use of Proceeds

Number of Owner
# of Owner
Principal Owner Information
Name*
First Last
Date of Birth*
Social Security Number*
% Ownership
Home Address*
Street Address State ZIP Code
Home Phone
Cell Phone*
Email Address
Principal Owner Information #2
Name*
First Last
Date of Birth
Social Security Number
% Ownership
Home Address
Street Address State ZIP Code
Home Phone
Cell Phone*
Email Address

Bank Statements
Please upload your bank statements from the past 4 months below.
Drop files here or

Let’s Work Together

We offer a personalized solution for a niche industry. The healthcare industry needs healthcare financing.

Our Commitment To You

“I love helping healthcare professionals grow their practices. I love enabling them to keep going and, if it’s their goal, to provide additional or improved services to a greater number of people. ”

Apply For Business Funding

Business Information

Financial Information

Number of Owner

Principal Owner Information

Principal Owner Information #2

Let’s Work Together

Address

Phone

Email

Our Commitment To You

MARISSA IGNATOWICH • FOUNDER

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