Express Application

Equipment Loan Express Application
Please fill in the information below. Information marked with an * is required to submit your request. When finished, click the "continue" button at the bottom of the page.

Personal Information

* Indicates required field

Name *

First

Last

Middle Initial *

Email *

Social Security Number *

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone *

Cell Phone *

Profession/Business Type: *

Professional License Number (if known): *

Number of Years Licensed: *

Practice information

Practice Name *

Practice Address *

Line 1

Line 2

City

State

Zip Code

Country

Practice Phone *

Practice Fax *

Practice E-Mail *

How many years has this business been open? *

What is your ownership percentage? *

Co Signer Information

Would you like to add a cosigner? *

Equipment & Vendor Information

Is the Equipment *

Total Purchase Price *

Financing Options You're Interested In

Payment Plan You're Interested In: (Number of months) *

Interested in 90 Day Payment Deferral? *

Contact

Preferred Contact Method *

Authorization and Disclosure

I hereby authorize the release of business and/or personal credit information to NCMIC Finance Corporation (NCMIC), its affiliates or assignees (1) from any source including credit bureau reporting agencies and my bank for the purpose of extending credit, and (2) to any credit reporting agency. I also hereby authorize NCMIC to order a credit report in connection with the administration, review, or collection of my account and in connection with offering additional products and services to me. Additionally if my application is not approved by NCMIC, I hereby authorize the release of my application without notice, to any other potential lending sources not related to NCMIC Finance Corporation for consideration of approval of credit. I hereby represent all information is true, correct and complete. A photo static, facsimile, or other electronic copy of this authorization shall be valid as the original. The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract), because all or a part of the applicant’s income derives from any public assistance programs, or because the applicant has in good faith exercised any rights under the Consumer Credit Protection Act. The federal agency that administers compliance with this law is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580. To help the Government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. This means that when you apply for credit or open an account with NCMIC we will ask for your name, address, date of birth, social security number, and other information that will allow NCMIC to identify you. We may also require that you furnish NCMIC with a copy of your Driver’s License or other identifying documents. Consult your attorney or financial advisor for specific legal and/or tax advice before entering into any type of financing arrangement, and for information on tax deduction eligibility and procedures. NCMIC AND THE EQUIPMENT VENDOR AND/OR BROKER YOU SELECT ARE SEPARATE COMPANIES, ARE NOT AGENTS OF ONE ANOTHER, AND HAVE NO AUTHORITY TO BIND ONE ANOTHER TO FINANCIAL OR OTHER CONTRACTUAL OBLIGATIONS.

I Read and Accept The Authorization and Disclosure.

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