Pre-Approval Credit Application

Print application, answer questions and fax to Dr. Robert Popick
Phone: (800) 526-5557  Fax: (561) 793-5311
drpopick@innovativehealthcaresystems.com


Company/Practice Information

LEGAL BUSINESS NAME: SPECIALTY:
BUSINESS ADDRESSES: COUNTY:
CITY/STATE/ZIP  
PHONE: FAX:
EMAIL: CELL:
YEARS IN PRACTICE: TAX ID:
EQUIPMENT: PRICE:

 

Personal Information

NAME: TITLE: OWNERSHIP%:
HOME ADDRESSES: CITY: STATE/ZIP:
CITY/STATE/ZIP    
HOME PHONE: CELL:  
SOCIAL SECURITY#: PROFESSIONAL LICENSE#:  
DATE OF BIRTH: ANNUAL INCOME:  
DO YOU HAVE A: CHECKING ACCT: YES ___ NO ___ SAVINGS ACCT:YES ___ NO ___
DO YOU: OWN YOUR HOME: YES ___ NO ___ RENT YOUR HOME:YES ___ NO ___

 

Partner Information

NAME: TITLE: OWNERSHIP%:
HOME ADDRESSES: CITY: STATE/ZIP:
CITY/STATE/ZIP    
HOME PHONE: CELL:  
SOCIAL SECURITY#: PROFESSIONAL LICENSE#:  
DATE OF BIRTH: ANNUAL INCOME:  
DO YOU HAVE A: CHECKING ACCT: YES ___ NO ___ SAVINGS ACCT:YES ___ NO ___
DO YOU: OWN YOUR HOME: YES ___ NO ___ RENT YOUR HOME:YES ___ NO ___

 

___________________________________________
 
____________________
Signature
 
Date
 
___________________________________________
 
____________________
Signature
 
Date

By signing this application I/we hereby authorize the release of business and/or personal credit information to Innovative Healthcare Associates, LLC and/or its assigns for the purpose of investigating my/our credit for the purposes of obtaining lease financing.  I/we certify that the information given herein is true and correct. A photo static and/or facsimile copy of this authorization shall be valid as the original. 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. What this means for you: When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.