NeuroVasix Credit Application

Apply Now: (Please complete the application and submit for review.)

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Business Information

* Complete Legal Business Name:

* Business Structure:

* Any Other Businesses Owned?

If so, how many?

* Annual Sales Of Business:

* Number Of Years In Business:

* Federal Tax ID Number:

* Number of Employees:

Location of Business

* Street Address:

* City:

* Zip:

* County

Location of Equiment to Finance

* Street Address:

* City:

* Zip:

* County

Business Manager

* Person to Contact

* Email Address:

* Phone Number:

Fax Number:

Alternate Phone:

Owner 1

* Title:

* Authorizing Officer Name:

* SSN:

Work Phone:

* %Owned:

* Street Address:

* City:

* Zip:

* County:

Owner 2 (if applicable)

Title:

Name:

SSN:

% Owned:

Work Phone:

Street Address:

City:

Zip:

County:

Banking Information

* Bank Name

* Business Account Number:

* Average Balance

* Contact Name

Work Phone:

Sales Order Details

* Please Briefly Describe What We Are Financing:

Supplier Information

* Sales Representative's Name:

* Phone Number:

* Finance Term (mo.):

* Total Cost Of Order:

* TOTAL Mo. 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

Apply Now: (Please complete the application and submit for review.)