Andrew J. Falso
(866) 859-4215
andrew.falso@medicalfundinggroup.com
5786 Widewaters Parkway
Dewitt, NY 13214


Online Application Form
   
*Legal Business Name:
Trade Name:
*Address Line 1:
Address Line 2:
*City:
*State/Province:
*Zip/Postal Code:
*Phone Number:
Fax Number:
   
*Contact Name:
*Contact Cell:
*Contact Email:
   
Federal ID Number:
*Years in Business:
No. of Locations:
Business Structure:
   
Personal Information of Officers/Partners/Owners
*Name:
*Title:
*Home Address:
*City/State/Zip:
SSN:
   
Name:
Title:
Home Address:
City/State/Zip:
SSN:
   
Name:
Title:
Home Address:
City/State/Zip:
SSN:
   
Banking References
Bank Name:
Account Number:
Phone:
Fax:
Contact:
   
Bank Name:
Account Number:
Phone:
Fax:
Contact:
   
Vendor Information
Name of Vendor:
Sales Rep:
Phone:
   
Equipment Information  *If different from above
Equipment Type:
Equipment Cost:
*Intended Address:
*Intended City/State/Zip:
Term Requested: 24 36 48 60
   
Customer authorizes Medical Funding Group, Inc. or its assigns to request, verify and review data or information about the customer, its officers, partners, owners and guarantors including reports from agencies and information from references. PCC is authorized to give credit information about customer to others. All information provided herein is correct and complete. If business credit is denied, customer has the right to a written statement of the specific reasons for the denial. To obtain this statement, please contact PCC at address shown above within 60 days of a denial. A fax or photocopy of this authorization shall be valid as the original.
   
 

   

Medical Funding Group, Inc. / 5786 Widewaters Parkway / DeWitt, NY 13214
Toll Free: 866-859-4215 / Fax: 866-316-7828 / andrew.falso@medicalfundinggroup.com