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Medical Practice Information
Contact First Name
Contact Last Name
Provider (Company) Name
Address 1
Address 2
City
State or Province	Select One AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - Washington DC DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming Not USA Select One
Zip Code
Phone
Cell Phone
E-mail
Fax
Corporate Structure	Corporation LLC Partnership Sole Proprietorship
State of Incorporation	Select One AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - Washington DC DE - Delaware FL - Florida GA - Georgia HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming Not USA Select One
Approximate Date of Incorporation
Years in Business
What type of healthcare services do you provide?
Do you have any outstanding loans that have liens on your accounts receivable? if yes how much?

Accounts Receivable Information:
Total Receivables Outstanding (do not include Self-Pay)
What is the approximate Net Realized Value (NRV) of Total Receivables Outstanding? (Approximately)
Monthly average sales? (Approximately)
Average number of days to collect? (Approximately)
Outstanding A/Rs over 90 days? (Approximately)
By what date would you like to have a your account ready to fund?
Marketing Information:
How did you find our web site?	Select Google Yahoo MSN Search engine AOL Search Business Journal AD Postcard Received BusinessFinance.com FedMarket.com Web Search Engine Magazine Ad Yellow Pages Other
What keywords or phrase did you use
If other, please specify