Business Information

Business Name *

Address *

City *

State *

Zip Code *

Work Phone Number *

First Name *

Last Name *

Home Street Address *

City *

State *

Zip Code *

Email Address *

Cell Phone Number *

Fax # *

Guarantor *

Medical License # *

Amount of Equipment *

Term Requested *

AUTHORIZATION: By submitting the above application and signing below, you certify that the information provided in this credit application is accurate and complete and you authorize Highland Capital Corporation, its successors and/or assigns to obtain information from the references listed and obtain a consumer credit report that will be ongoing and relate not only to the evaluation and/or extension of the business 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. We will obtain your information submitted through the e-signature system. By completing this form you acknowledge and authorize the acceptance of your electronic signature by Highland Capital and its affiliates for the purpose of obtaining credit approval. I hereby certify that my electronic signature is legally binding as if originally signed and constitutes my acceptance to all terms and conditions. The individual signing or submitting this application further waives any right or claim, which such individual would otherwise have under Fair Credit Reporting Act in the absence of this continuing consent.

ECOA NOTICE (TO BE RETAINED BY APPLICANT): Your business credit application will be reviewed carefully and a decision will be rendered promptly. If your business credit application is denied you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact Highland Capital Corporation at 5 Center Avenue, Little Falls, NJ 07424 within 60 days from the date you are notified of our decision. We will send you a written statement of the reasons for denial within 30 days of receiving your request. The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, natural origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Office of the Comptroller of the Currency (OCC) Customer Assistance Group, 1301 McKinney St., Suite 3450, Houston, Texas 77010-3031.

Acceptance *

Authorize / Acknowledge

Date * +