Loan Inquiry - American Healthcare Capital

SELECT LOAN BEING APPLIED FOR:*

Accounts Receivable Financing

Term Loan

SBA Loan

Cash Advance Loan

Mezzanine Financing

Equipment Financing

Real Estate Financing

Business Name*

Title *

Cell Phone*

Business Phone*

Company Website*

Full Name*

Email*

Business Address*

Street Address City State / Province / Region Postal / Zip Code Country

Business Type*

Are there Loans Outstanding? *

Yes

No

Are There Back Taxes Owing?*

Yes

No

Legal Structure *

If yes, how much?

If yes how much?

Gross Revenue - Last Calandar Year*

Average Monthly Revenue - Current Year*

Accounting Software Used

Enter the Percentage (%) of Receivables From the Following Payors

Enter the Percentage (%) of Receivables From the Following Pages(1)

Enter in the Percentage (%) of Receivable From the Following Payees

Enter the Percentage (%) of Receivables From the Following Pages (3)(1)

Enter the Percentage (%) of Receivables From the Following Pages (3)

Net Income - Last Calendar Year*

Current New A/R Balance Under 180 Days*

Name of Medical Billing Provider, if any

Maximum Credit Amount Requested*

Planned Use of Funds*

Additional Notes