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applicatioon

Apply for Financing

Business Information

Please note the following fields are required: Company Name, Office Phone, Email Address

Legal Company Name & any DBAs*

Company Address, City, State, Zip, Country

Federal Tax ID #

Office Phone #*

Date Business Incorporated

Primary/Best Email Address*

Annual Business Revenue

Services Currently Offered

Website Address/es

Additional Contact Person

Personal Information

Owner Name

% Ownership

SSN / SIN

Date of Birth

Cell #

HomeAddress,City,State,Zip,Country

Own / Rent?

Est. Market Value

Home #

Occupation / Medical Specialty

Date Med. License Issued

Name of Med. Practice/Other Biz

Personal Gross Income / Yr

% Ownership: Med. Practice/Other Biz

Est. Value of Cash Investments / Savings

Financing Preferences

Preferred Down Pmt

Preferred Pmt / Mo

3, 4, or 5 Yr Term

Deferred Pmts If Avail.?

Delivery Date

By signing below, you certify that the information provided in this application is complete and accurate. The undersigned individual as principal of and/or guarantor for the applicant, authorizes Rocket Funding Group, LLC, its designee, assigns or potential assigns, including but not limited to Capital Toolbox, Accrete Enterprises, and H.I.L. Financial, to review his/her personal credit profile provided by national credit bureaus in considering this Application and for the purpose of the update, renewal, or extension of credit to the Applicant or the collection of any resultant accounts. The authorization will be ongoing and relate not only to the evaluation and/or extension of the business credit extended, but also for the purpose of reviewing the account. By the execution of the lease agreement, I/We warrant that the information submitted herein is true and correct and hereby authorize that any bank, lending institution, supplier, person or consumer reporting agency should comply and furnish any information Lessor deems necessary in connection with this Application. Any and all disputes must be heard in the county of Travis, state of Texas. Further, I/We warrant it is understood that Lessor reserves the right to reverse any credit decision if the information contained herein is found to be incorrect, and I/We will indemnify Lessor for any and all costs incurred with this application for credit including any cost incurred in the placement or reservation of the intended leased equipment based on the information contained herein.

The Federal Equal Credit 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, D.C. 20580. If your application for credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact Lessor set forth above within sixty (60) days from the date you are notified of our decision. We will send you a written statement for reasons of denial within thirty (30) days of receiving request for the statement.

 I agree to the terms above.*