Dental Practice Loan Application Form

Type of Credit Facility Requested?*

Applicant is*

BorrowerCosignerGuarantorOther

Name of Business*

Business Inception Date*

Date

Name of Owner/Guarantor *

Business Phone Number*

Cell Phone Number*

Years in Business (MUST be in business 1 year or longer)*

Must be in business longer than 1 year

Title*

Number of Employees*

Revenue for the Business in 2020 (MUST be greater than $100K)*

Must be greater than $100,000

Net Income for the Business in 2020*

Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Applicant Status*

New ClientExisting ClientOther

Business Classification*

Business Email*

example@example.com

Nature of Business*

Loan Amount Requested*

Desired Loan Term*

How much do you process in debit/credit card payments per month

Purpose of your Loan (important items to note)*

Personal Annual Income*

I/We hereby affirm this application for loan or credit as specified above in this application form, on behalf of the business applicant. The information specified above provided are true and correct to the best of my/our knowledge and with no intention to commit acts of misrepresentation. No addition or omission has been made which may lead to acts of fraud or any form of impropriety. I/We agree that the Lender or its affiliates is authorized to conduct any form of investigation in order to verify and confirm our declarations and requests, including, but not limited to conduct any investigation of my/our credit standing. Lender or its affiliates may disclose financial information of our account to any other lender or its affiliates which may be needed for disclosure in relevance to credit investigation.

Signature*

Name*

IF YOU PROCESS DEBIT AND CREDIT CARDS PLEASE UPLOAD LAST 3 MONTHS OF BUSINESS BANKING STATEMENTS

Date Signed*

Date

Welcome to Dental Practice Lending

We Are Dentists Preferred Lending Partner

Dental Practice Loan Application Form