HEALTHCARE FINANCING APPLICATION

Healthcare Provider Number:___________________________________________(Office Will Supply)
Are you a co-borrower?_____If so, for whom:____________________________________________
This Healthcare Line of Credit is secured by a 2nd mortgage.

---------------------------------PLEASE PRINT YOUR PERSONAL INFORMATION-------------------------------------

Husband________________________________Wife_____________________________________
Address_________________________________________________________________________
_______________________________________________________________________________
Home Phone #(____)__________________Best time to call________________________________

Husband's Cell Phone #(        )_______________Husband's Work Phone #(       )_______________
Wife's Cell Phone #(       )___________________Wife's Work Phone #(       )___________________
Husband's Employer_____________________________________Phone #(       )_______________
Job Title__________How Long Employed_________SS#__________Gross Monthly Pay $_________
(Yes) or (No): Checking Account_______Savings Account_______401K Plan______IRA Plan_______
Wife's Employer________________________________________Phone #(        )_______________
Job Title__________How Long Employed_________SS#__________Gross Monthly Pay $_________
(Yes or (No): Checking Account________Savings Account_______401K Plan______IRA Plan_______


----------------------------------------REAL ESTATE INFORMATION----------------------------------------------------
Name(s) on 1st Mortgage___________________________________________________________
Date Financed____________Estimated Value $____________Any 2nd Mortgage Now___________
1st Mort.Bal. $___________________               Rate____________  Fixed(    )or Adjustable(     )
Yearly Property Taxes $__________Yearly Homeowner Ins. $_________Inc. in Pmt. Yes(    ) No (    )

I (We) hereby authorize this Healthcare Facility and/or its agents, partners, transferees and assigns
to obtain any credit reports and other information deemed necessary to complete said credit review,
and, to assign, sell or transfer any obligation resulting from this application to any individual,
company or institution of its choice. I (We) understand that any loan, resulting herewith, made to
me (us), either as a borrower, or a co-borrower, to pay for patient services rendered, at the full
discretion of the lender, that I (we) are fully responsible for the repayment of the resulting line of
credit, or loan, in its entirety, in accordance with its terms and conditions, as set forth.

Patient's Full Name:________________________________________________________________

Borrower(s) Signature:________________________*________________________Date_________

Co-Borrower(s)Signature:______________________*________________________Date_________

Witness to Signature(s):________________________________________________Date_________


                                                                  SE HABLA ESPANOL

       RETURN THIS FORM TO YOUR PROVIDER FOR OUR PROCESSING WITHIN THE NEXT 24 HOURS!