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Working Capital Application                       
* Required Fields *
    Business Information      
*Business Name:  
*Date Opened:  month: year:
*State:     * Zip:    County:
*Phone:     * Fax:
Cell Phone :  
* Email:  
* Profession:   Example: Medical Doctor, Dentist, Surgeon.
  *Current License   *State:
  Original License   State:
Corporation Proprietorship   Partnership
Landlord Contact: Phone:
Office Insurance Contact: Phone:
    Personal Information
*Name:   Title:
*Home Address:  
*State:     * Zip:    County:
*Home Phone:  
* Date of Birth:      
    Business Bank Information
*Bank:       *Type Acct: * Date Opened:
* Bank Phone:   Contact:
    Amount Requested
$25,000  $50,000  $75,000  $100,000 $150,000 Other $
    What is the Proposed Use of the Funds?

For the purpose of securing a working capital loan, I authorize all bank deposit, credit, trade and borrowing information to be released by telephone or facsimile transmission.
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Medical Financial & Leasing Associates, Inc.
6368 Shadow Creek Village Circle, Lake Worth, FL 33463
Office (866) 963-6850 * Fax (561) 963-6904