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Express Lease Application

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Practice Information

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

Purchase Price

 

Personal Information

Name

 

Street Address

 

City

 

State

 

Zip

 

Phone

 

Social Security Number

 

Professional License

 

Do You Have

Checking    Savings    Both

Home:

Monthly Payment

 

Lease Program & Terms

Program

$1.00 Buyout at end of term (more info)
10% Buyout at end of term
 (more info)

Term in months

  (more info)

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.
 

I Agree

 

 

   Enter the Code You See to the Left

 

 

   
     
 

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