Credit Application - ClientOriginationPortal

Credit application

Note: Asterisk (*) symbol indicates 'Required' field

Required

Legal Entity Name (as registered with the Secretary of State)

Dba (doing business as)

Optional

Street address

Suite

Optional

Zip (5 digits)

State abbr. (e.g. NJ)

City

Business phone (e.g. 888-888-8888)

Tax id (e.g. 99-9999999)

Optional

Contact name

Contact Email

Amount (e.g. 75000.00)

Term (months)

Optional

Payment structure

Optional

Equipment Vendor Name

Optional

Equipment sales representative

Optional

Personal guarantor 1 (Required if less than 3 owners)

Personal Guarantor

Use business address

First name

Last name

Street address

Suite

Optional

Zip (5 digits)

State abbr. (e.g. NJ)

City

Mobile phone (e.g. 888-888-8888)

Optional

Fax (e.g. 888-888-8888)

Optional

Date of birth (mm/dd/yyyy)

Optional

Social security # (e.g. ***********)

Show

Pg authorization

Individual receiving consent

Personal guarantor 2 (Optional)

Personal Guarantor 2

Use business address

First name

Last name

Street address

Suite

Optional

Zip (5 digits)

State abbr. (e.g. NJ)

City

Mobile phone (e.g. 888-888-8888)

Optional

Fax (e.g. 888-888-8888)

Optional

Date of birth (mm/dd/yyyy)

Optional

Social security # (e.g. ***********)

Show

Pg authorization

Individual receiving consent

Personal guarantor 3 (Optional)

Personal Guarantor 3

Use business address

First name

Last name

Street address

Suite

Optional

Zip (5 digits)

State abbr. (e.g. NJ)

City

Mobile phone (e.g. 888-888-8888)

Optional

Fax (e.g. 888-888-8888)

Optional

Date of birth (mm/dd/yyyy)

Optional

Social security # (e.g. ***********)

Show

Pg authorization

Individual receiving consent

By providing this information, I attest to be either a principal of the credit applicant or a personal guarantor of its obligations, and hereby provide written permission to EverBank and its designee and / or assignee) to review my 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 updating, renewing or extending such credit or additional credit and for reviewing or collecting the resulting account.

Comments & attachments (Please attach equipment quote or invoice here, if available.)

Comment

Optional

Upload document (optional)

Optional

Allowed file formats: bmp, csv, dat, doc, docx, eml, gif, jpeg, jpg, mdi, msg, note, odt, pdf, png, rtf, tif, tiff, txt, vcf, xls, xlsx

Internal comment

Optional

Upload document (optional)

Optional

By submitting this application to us electronically, I/We acknowledge and affirm my/our identity as the respective individuals identified in the above application.

IMPORTANT INFORMATION ABOUT PROCEDURES FOR COMMENCING A NEW ACCOUNT

For security purposes and to help the government fight terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person or commercial entity who opens an account or obtains financing. For this reason, we will ask you for your name, address, date of birth, Social Security or other Tax Identification Number, and other information that will allow us to identify you. We may also ask other questions or request other documents meant to verify your individual or commercial identity.

Note: if your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. If you would like a statement of specific reasons why your application was denied, please contact our Representative at EverBank, N.A., 10 Waterview Boulevard, Parsippany, NJ 07054, 1-877-275-8795 within 60 days of the date of this letter. We will provide you with the statement of reasons within 30 days after receiving your request.

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 part of the applicant’s income derives from any public assistance program or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Bureau of Consumer Financial Protection, 1700 G Street NW, Washington DC 20552.

Need Help?

Please reach out to our

Relationship Manager

Marty Fitzgerald

Martin.Fitzgerald@EverBank.com

or call

O: 973.576.0631

Healthcare financing made simple with EverBank

EverBank is a leading lender to the healthcare industry. Our Healthcare Equipment Finance team provides a winning combination of industry experience, team dedication, and technological advancements to customize financing solutions to meet your unique needs. We can help you manage equipment acquisitions with an eye on the growth of your business. No matter the size of your project, we make financing quick and easy.