Pre-Approved Lease/Purchase Program

Personal Information

Name*

First Name (as listed on driver's license)Last Name

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Social Security Number*

(as xxx-xx-xxxx)

Cell Number*

Practice Information

Practice Name*

(Legal business name registered with the Secretary of State and/or DBA)

Business Tax ID Number*

(as xx-xxxxxxx)

Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Practice Phone*

Practice FAX

Practice Email*

Your e-mail address will never be shared or sold. It will be used to send you important notices.

Profession /Business Type

Professional License Number (if known):

Number of Years Licensed:*

How many years has this business been open?*

Years

What is your ownership percentage?*

Equipment & Vendor Information

Primary Equipment Type: (Select one or more)*

MATRIX System™ (software version 1/1.0)MATRIX PMT System™ (software version 2/2.0)MATRIX SPORTS System™ (software version 2/3.0)NeuroSanos Unit™ (software version 5/1.0)Other not listed

Financing Options You're Interested In

Interested in 90 Day Payment Deferral?

YesNo

Payment Plan You're Interested In: (Number of months)

Preferred contact Method*

Practice EmailPractice PhoneCell PhoneHome Phone

Other Phone

Please enter a valid phone number.

Other Email

Authorization and Disclosure

NeuroMed Consulting, Inc. (NeuroMed) will be providing this application to an outside Lender / Financier or Leasing Company (not affiliated with NeuroMed) for approval and processing of the purchase of said equipment.

I hereby authorize the release of business and/or personal credit information to Lender / Financier or Leasing Company, its affiliates or assignees (1) from any source including credit bureau reporting agencies and my bank for the purpose of extending credit, and (2) to any credit reporting agency.

Additionally if my application is not approved by Lender / Financier or Leasing Company, I hereby authorize the release of my application without notice, to any other potential lending sources not related to NeuroMed for consideration of approval of credit. I hereby represent all information is true, correct and complete. A photo static, facsimile, or other electronic copy of this authorization shall be valid as the original.

The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract), because all or a part of the applicant’s income derives from any public assistance programs, or because the applicant has in good faith exercised any rights under the Consumer Credit Protection Act.

The federal agency that administers compliance with this law is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580. To help the Government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account.

This means that when you apply for credit or open an account with Lender / Financier or Leasing Company they will ask for your name, address, date of birth, social security number, and other information that will allow Lender / Financier or Leasing Company to identify you. They may also require that you furnish Lender / Financier or Leasing Company with a copy of your Driver’s License or other identifying documents.

Consult your attorney or financial advisor for specific legal and/or tax advice before entering into any type of financing arrangement, and for information on tax deduction eligibility and procedures. NeuroMed THE EQUIPMENT VENDOR AND/OR BROKER /OR THE FINANCIAL PROVIDER YOU SELECT ARE SEPARATE COMPANIES, ARE NOT AGENTS OF ONE ANOTHER, AND HAVE NO AUTHORITY TO BIND ONE ANOTHER TO FINANCIAL OR OTHER CONTRACTUAL OBLIGATIONS.

Date*

Date

Signature*