Physician/Owner Name (required) Your Email (required) Phone Number (required) Fax Number Business Name (required) Tax ID Social Security Number (required) The undersigned certifies that the information requested above is true, correct and complete. Each signer of this Application certifies that he or she is authorized to execute this authorization and release regarding credit and other information on behalf of the Applicant to all Lessors and Credit Reporting Entities (defined below). Lessee acknowledges and agrees that: (1) All information provided pursuant to this application will be used by banks, leasing companies and other financing entities (“ L.essors”) for purposes of determining whether Lessee may or may not qualify for potential financing opportunities. (2) Each Lessor will perform rts own credit quantification analysis and Lessor may or may not decide to extend credit to Lessee. (3) Execution of this application in no way implies. or is intended to imply that a decision by Lessor has been made or that credit will be granted by any or all Lessors. (4) Vendor has no involvement whatsoever in any of the analysis or credit decisions to be made by any or all of the Lessors, and Vendor has no obligation to provide Lessee with an explanation as to why any or all such Lessors have declined to extend credit to Lessee. Lessee, its owners and/or principals, and all individuals whose names appear on the application expressly. (1) Authorize consumer reporting agencies, banks and all other persons ("Credit Reporting Entities") to furnish credit and other information to any or all Lessors, separately or jointly with other creditors or lessors, for use in connection with, or for the purpose of, extending credit. (2) Authorize Lessors, Credit Reporting Entities, and joint users of such credit and other information to receive and exchange such information and to update such information as appropriate during the term of any Agreement, if any, resulting from this Application. 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, because of 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. You have the right to a written statement of the specific reasons for any denial of credit. The lender will either contact you by phone or send you a written statement of reasons for the denial within 30 days. Your Full Name (required) Today's Date (required) Representative Sign Below (required)