Please fill out our 2-Minute Application and we will contact you within 24 hrs of receipt. 

You can also download a PDF version of the application. 

Simply fill out and fax back to us at 972-516-3892.

If you need to download Acrobat Reader, please click here. 

(Chiropractors: Must be owner of Practice for 5 years minimum)

* Denotes Required Field.

Funds Needed: *	- Select - $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000 $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 $105,000 $110,000 $115,000 $120,000 $125,000 $130,000 $135,000 $140,000 $145,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 Other
Where did you hear about us?:	- Select - Google Yahoo Other Search Engine Medical Journal Postcard Colleague Friend Other
What is the proposed use of the Funds: *
Legal Name of the Business / Practice: *
Federal Tax ID#: *
Time in business: *	Year(s)
Email Address: *
Practice Address:
Practice City:
Practice State:	- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Practice Zip Code:
Type of Business / Practice Structure:	- Select - Sole Proprietorship Professional Association (P.A.) Professional Corporation (P.C.) L.T.D Corporation S Corporation Partnership Limited Liability Corporation (L.L.C.) Professional Limited Liability Corporation (P.L.L.C.) Limited Liability Partnership (L.L.P.) Publicly Traded Non-Profit
Specialty: *
Physician's Full First and Last Name Applying: *
Personal Social Security #: *
Date of Birth: *
Home Address: *
Home City: *
Home State: *	- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Home Zip Code: *
Home Phone #:
Business Phone #: *
Business Fax #: *
Other Phone #:
Business Annual Gross Income:
Annual Personal Gross Income:
Net Worth:
Medical Related License #: *
Date First Licensed: *
Bank Name:
Avg. Checking Balance:	$
Avg. Savings Balance:	$
Account #:
Bank Telephone #:
Bank Contact Person:
By initialing the application where indicated on this loan application I hereby authorize the release of all credit information, including loans, leases, checking, savings, trade references and personal credit history, pertaining to the company, its principles, and the people listed below to Doctorfunds.com and/or its designees or assignees. Such authorization shall extend to sub sequent updates for credit and collection purposes.
Initial: *