Complete this Form to Offer Premium Financing to Your Customers, Clients, or Patients
...And Sell More of Your High-Ticket Products, Services, or Procedures.
Contact Name (Business Owner Only)
*
First Name
Last Name
Additional Owner or Contact Name (If none type N/A)
*
First Name
Last Name
Business Name (Practice)
*
Registered Corporate Name
DBA Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email (Business Owner's Best Direct Email)
*
example@example.com
2nd Owner or Contact Person's Email (If none, type N/A)
*
example@example.com
Phone Number (Business)
*
Please enter a valid phone number.
Phone Number (Mobile)
*
Please enter a valid phone number.
2nd Owner or Contact Name's Mobile Number (If none, Type 000.000.0000)
*
Please enter a valid phone number.
Have you made arrangements with us or anyone else to procure up to $26K per Employee, for you, via the Employee Retention Credit Program?
Yes
No
Specialty (Optional, but would be helpful)
Do You Currently Offer Consumer Financing
*
Yes
No
If you answered Yes, let us know with who and what pain points you are experiencing with your current provider? Please provide as much information as possible; to help you best with this opportunity. If you don't offer financing, type N/A
*
Current Monthly Financing Volume. If not providing financing, type $0
*
Average Item/Service/Procedure Package [High-Ticket Amount] ($) (Required for Eligibility to Provide Best Financing Options)
*
Gross Annual Sales ($) (Required for Eligibility to Provide Best Financing Options)
*
Business Established Date (Required to be considered to Provide Financing)
*
State of Incorporation (Required for State Eligibility)
*
Sales Process
*
Face-to-Face
Online
Other
Agent Name
Agent #
Please verify that you are human
*
Submit
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