Please provide the following information to help us initially in determining your financing needs. This form shall be emailed to us and within 24 hours you shall be contacted by one of our qualified representatives to answer any questions and provide more detailed information. If you prefer, you can contact us directly by calling our corporate offices toll free at 888-546-3446 during regular business hours. Please complete the entire form. Business/Organization Name: Personal Name (First & Last): Title: Owner / President Business Buyer Busines Seller Financial Advisor Other E-mail: Street, PO, & Apt #: City, State, Zip: Phone: Fax: Business Type: Financing Amount: Primary Use of Funds: Equipment Financing & Leasing Accounts Receivables Factoring Export/Trade Financing Franchise Financing Gas Stations & Car Washes DIP Financing Church Financing Commercial Real Estate Financing Hotels & Motels Hard Money / Sub-Prime Construction & Renovation SBA Financing Medical Equipment Leasing Practice Acquisition Financing Working Capital Loans Other How Soon You Need to Close: Under 30 days 30 - 60 days Over 60 days Brief Description of Loan: Preferred Contact Mode: Phone Email Fax Best Time to Call: Morning Afternoon Evening

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