Credit Application

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Amerisource: neuroVasix Credit Application

Business Information

Complete Legal Business Name:
Business Structure:
Any Other Businesses Owned?
How Many?
Annual Sales Of Business:
Number Of Years In Business:
Federal Tax ID Number:
Number of Employees:

Location Of Business

Address:
City:State:
County:Zip:

Location Of Equipment to Finance

Address:
City:
County:
Zip:

Business Manager

Phone Number
Fax Number:
Alternate:
Person to Contact:
Email Address To Expedite Request:

Owner 1

Authorizing Officer - Name:
Authorizing Officer - Title:
Social Security
% Owned:
Phone Number:
Home Address:
City:State:
County:Zip:

Owner 2 (if applicable)

Authorizing Offer - Name:
Authorizing Offer - Title:
Social Security:
% Owned:
Phone Number:
Home Address:
City:
County:Zip:

Banking Information

Bank Name:
Business Account Number:
Average Balance:
Contact Name:
Phone Number:

Sales Order Details

How many MicroVas Systems are we Financing
(Include Serial Number(s)):

Supplier Information

Sales Representative's Name:
Phone Number:
Finance Term In Months:
Total Cost Of Order:
Approximate TOTAL Monthly Payment Quoted:

THE UNDERSIGNED ACKNOWLEDGES THAT AMERISOURCE LEASING SERVICES, LLC AND ITS ASSIGNEES WILL BE REVIEWING OUR BUSINESS CREDIT PROFILE INCLUDING OUR PERSONAL CREDIT BUREAU REPORTS AND BY SUBMITTING THIS APPLICATION FORM GAINS OUR PERMISSION TO DO SO.

(800) US MONEY / Fax (713) 460-1364

Patrick Kistler, President, Leasing Division, ext. 410