Legal Name

Street Address

City

State

Zip

Phone

Fax

Email

Years in Practice

Specialty

Annual Gross Revenue from Practice

Net Annual Income after Expenses

Item Purchasing

Direct Connect Laser w/10-foot cord Portable Cordless Laser Unit

Purchase Price

Personal Information

Name

Street Address

City

State

Zip

Phone

Social Security Number

Professional License

Do You Have

Checking    Savings    Both

Home:

Own Rent

Monthly Payment

Lease Program & Terms

Program

Term in months

Applicant hereby authorizes the release of business and/or personal credit information to Professional Solutions Financial Services, its affiliates and partners, (1) from any source including credit bureau reporting agencies and applicant’s bank for the purpose of extending credit, (2) to any credit reporting agency. I hereby represent all information is true, correct and complete. A photo static and/or facsimile copy of this authorization shall be valid as the original. If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact: Credit Operations, Professional Solutions Financial Services, 14001 University Avenue, Clive, Iowa 50325-8258 within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement. PSFS complies with Section 326 of the USA Patriot Act. The law mandates that we request and verify certain information about you and your company.
 

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