Smart Med Biz
Account Verification Form
1306 South Dupont Highway
Dover, DE, 19901
(561)877-4437
www.smartmedbiz.com
Legal Company Name
*
DBA Name
State Incorporated
*
Legal Entity
*
Please Select
Corporation
LLC
Partnership
Sole Proprietorship
Other
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Business Address (no PO BOX)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Phone Number
*
Please enter a valid phone number.
Contact
*
Title
Email
*
example@example.com
Website
Employer Identification Number
*
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Years in Business
*
Type of Business
*
Credit Requested
*
Equipment Purchase
Vendor Equipment Invoice
Browse Files
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Choose a file
Cancel
of
Term
Please Select
12 months
24 months
36 months
48 months
60 months
Bank Statments
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Choose a file
Cancel
of
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Name of Owner (1)
*
Percentage of Ownership
*
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
US Citizen
*
Please Select
YES
NO
Rent/Own
*
Please Select
Rent
Own
Home Address (no PO BOX)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Name of Owner (2)
Percentage of Ownership (2)
Home Phone Number (2)
Please enter a valid phone number.
Mobile Number (2)
Please enter a valid phone number.
Date of Birth (2)
-
Month
-
Day
Year
Date
Social Security Number (2)
US Citizen (2)
Please Select
YES
NO
Rent/Own (2)
Please Select
Rent
Own
Address (no PO BOX) (2)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Signature (1)
*
Printed Name of Signature (1)
*
Signature (2)
Printed Name of Signature (2)
Each individual signing above certifies that the information provided in this application is accurate and complete. Each individual signing authorizes you, to whom this application is made, or your agents or assigns, to obtain information from the references listed above and obtain a consumer credit report that will be ongoing and relate not only to the evaluation and/or extension of the business of the credit requested, but also for purposes of reviewing the account, increasing the credit line on the account (if applicable), taking collection action on the account, and for any other legitimate purpose associated with the account as may be needed from time to time. Each individual signing further waives any right or claim, which such individual would otherwise have under the Fair Credit Reporting Act in the absence of this continuing consent. All aprovals are subject to the verifcation of time in business and complete description of the equipment.
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