Equipment Loans Request - Professional Solutions

Please fill in the information below. Information is required unless noted as optional. When finished, click "Submit Request” at the bottom of the page.

All fields marked with * are required.

Personal Information

First Name: *

(as listed on driver's license)

Middle Initial (Optional):

Last Name: *

Social Security Number: *

Home Address: *

P.O. Box, Apt., Ste., etc. (Optional):

City: *

State: *

ZIP: *

Cell Phone: *

Preferred E-Mail: *

Profession/Business Type: *

Professional License Number (If known) (Optional):

Number of Years Licensed: *

Business information

Business Name: *

(Legal business name as registered with the Secretary of State; if sole prop or IC, type your name.)

DBA, if applicable (Optional):

Business Address: *

P.O. Box, Apt., Ste., etc. (Optional):

City: *

County: *

State: *

ZIP: *

Business Phone: *

How many years has this business been open? *

Business Info

Gross Annual Revenue from Business ($): *

Net Annual Income from Business: *

What is your ownership percentage? *

Co Signer Information

Would you like to add a cosigner? *

Yes No

Cosigner Info

First Name: *

Middle Initial (Optional):

Last Name: *

Social Security Number: *

Home Address: *

P.O. Box, Apt., Ste., etc. (Optional):

City: *

State: *

ZIP: *

Cell Phone: *

E-Mail: *

Profession (Optional):

Annual Income (Optional):

Equipment & Vendor Information

Type of Equipment you would like to finance: *

Amount you are interested in financing ($): *

(Do not include dollar sign)

Have you selected a vendor? (Optional)

Yes No

Vendor

Primary Vendor Company Name (Optional):

Contact Name (Optional):

Contact Phone (Optional):

Contact Email Address (Optional):

Is there another vendor you are working with? *

Yes No

Vendor

Additional Vendor Company Name (Optional):

Contact Name (Optional):

Contact Phone (Optional):

Contact Email Address (Optional):

Are you working with more than 2 vendors? *

Yes No

Financing Options You're Interested In

Payment Plan You're Interested In:(Number of months)(Optional)

12 24 36 48 60

Interested in 90 Day Payment Deferral? (Optional)

Yes No

Do you have an invoice or financial document(s) you'd like to provide at this time? (Optional)

Yes No

Documents

Please attach document(s):

Comments Comments

Documents

If you have any documents you would like to send us, you can securely upload them now or email them to equipmentfinance@psfs.com.

Authorization and Disclosure

I/we hereby authorize the release of business and/or personal credit information to Professional Solutions Financial Services, a division of NCMIC Finance Corporation (NCMIC), its affiliates or assignees (1) from any source including credit bureau reporting agencies and my bank for the purpose of extending credit, and (2) to any credit reporting agency. I also hereby authorize NCMIC to order a credit report in connection with the administration, review, or collection of my account and in connection with offering additional products and services to me. Additionally if my application is not approved by NCMIC, I/we hereby authorize the release of my application without notice, to any other potential lending sources not related to NCMIC Finance Corporation for consideration of approval of credit. I/we hereby represent all information is true, correct and complete. A photo static, facsimile, or other electronic copy of this authorization shall be valid as the original. The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applications on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract), because all or a part of the applicant's income derives from any public assistance programs, or because the applicant has in good faith exercised any rights 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. To help the Government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. This means that when you apply for credit or open an account with NCMIC we will ask for your name, address, date of birth, social security number, and other information that will allow NCMIC to identify you. We may also require that you furnish NCMIC with a copy of your Driver's License or other identifying documents. Consult your attorney or financial advisor for specific legal and/or tax advice before entering into any type of financing arrangement, and for information on tax deduction eligibility and procedures. NCMIC AND THE EQUIPMENT VENDOR YOU SELECT ARE SEPARATE COMPANIES, ARE NOT AGENTS OF ONE ANOTHER, AND HAVE NO AUTHORITY TO BIND ONE ANOTHER TO FINANCIAL OR OTHER CONTRACTUAL OBLIGATIONS.

* I have read the Authorization and Disclosure and:

I accept

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