Individual Legal Name

Corporate Name

Business Number

Business Fax

Business Address

Email Address

Home Address

Date of Birth

SIN #(Optional)


Years in Practice

University Graduated

Reason for Request


Leasehold Improvements


Office Furniture



Real Estate

Total Amount of Request

Were you referred by anyone (if yes, please indicate who)

You confirm that the information you have given us in respect of this application is true and complete, and you authorize us to rely on and use this information in order to confirm your identity, evaluate your credit worthiness, in relation to the financing contract being entered into. In particular, you agree that we, our affiliates and any third parties acting for us or on our behalf (hereinafter collectively "us", or "we" or "our"), may obtain a credit report or other credit information from any credit reporting agency, credit bureau or credit grantor, and may hold, use, exchange and disclose such information for the purposes identified above. If your application is approved, you authorize us to collect, hold, use, exchange and disclose your personal information, as required, in order to administer your contract, determine your insurance eligibility, and secure the assets being financed, or as required or permitted by law. You also authorize us to use your personal information for internal statistical analysis purposes.

Consent Respecting Personal Information. Please read consent form and check box.


Providing Innovative Financing

Solutions to Healthcare Professionals


Credit Application