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Comments

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Vendor's Name

Estimated Cost

Finance Term

Deferral

Equipment Description

Legal Business Name

Business Structure

Corp.

Sole Prop.

Partnership

LLC

Other

Business Phone Number

Tax ID Number

Years In Business

Business Address

Street Address City State / Province / Region ZIP / Postal Code

Diff. Equipment Location

Check if the equipment is at a different location

Different Equipment Location

Street Address City State / Province / Region ZIP / Postal Code

Select Number of Owners

Owner 1 Name*

Owner 1 Type of License (if any)

Owner 1 Email address*

Owner 1 Cell Phone Number*

Owner 1 Social Security Number

Owner 1 Home Address

Street Address City State / Province / Region ZIP / Postal Code

Owner 1 Percentage Ownership

Owner 2 Name

Owner 2 Type of License (if any)

Owner 2 Email address

Owner 2 Cell Phone Number

Owner 2 Social Security Number

Owner 2 Home Address

Street Address City State / Province / Region ZIP / Postal Code

Owner 2 Percentage Ownership

Owner 3 Name

Owner 3 Type of License (if any)

Owner 3 Email address

Owner 3 Cell Phone Number

Owner 3 Social Security Number

Owner 3 Home Address

Street Address City State / Province / Region ZIP / Postal Code

Owner 3 Percentage Ownership

Owner 4 Name

Owner 4 Type of License (if any)

Owner 4 Email address

Owner 4 Cell Phone Number

Owner 4 Social Security Number

Owner 4 Home Address

Street Address City State / Province / Region ZIP / Postal Code

Owner 4 Percentage Ownership

Business Contact Name

Contact Person's Phone (If not listed above)

Contact Person's Email (If not listed above)

Preferred Method of Communication

Downloadable Credit Applications

QuickApp for One Owner Practices
QuickApp for Multi-Owner Practices
QuickApp for Hospital/Institutional Customers

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Downloadable Credit Applications

Funding Manager

Jon Vermeulen

Funding Manager

Kevin Zylstra

Funding Manager

Andrew Martinson

Contact Info

Phone

800-770-8550

Fax

952-854-4447

Email

oneStop@financialcorpleasing.com

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