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anthem2020
2022-08-17T00:56:44+00:00
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" indicates required fields
Legal Entity Name
*
Business Address
*
Street Address
City
State
ZIP / Postal Code
Business Phone Number
*
Website
Time In Business
*
State Of Incorporation
*
Email Address
*
Tax ID
*
Contact Name and Title
*
Principal's Info:
Owners Legal Name
*
Home Address
*
Street Address
City
State
ZIP / Postal Code
Cell Phone
*
SSN
*
Date of Birth
*
Month
Day
Year
% of Ownership
Email Address
*
Medical License # - State - Year Licensed
Is there an additional principle?
*
Please select...
Yes
No
Additional Principal's Info
Owners Legal Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Cell Phone
SSN
*
Date of Birth
*
Month
Day
Year
Ownership
Email Address
Medical License # - State - Year Licensed
Vendor Info:
Supplier/Vendors Name
*
Equipment Description
*
Cost of Equipment
Sales Rep Info
*
By submitting your application via this website, the undersigned individual, who is either a principal of the credit applicant or a personal guarantor of its obligations, provides written instruction to Prime Health Financial Or its designee (and any assignee or potential assignee thereof) authorizing review of his/her personal credit profile from a national credit bureau. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for the purposes of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account. A Photostat or facsimile copy of this authorization shall be valid as the original. By submitting your application via this website, I/we affirm my/our identity as the respective individuals identified in the above application.
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