Apply Now
Click the link to download a copy of our credit application or simply complete and submit the web form below. Complete downloaded forms should be emailed to kenpringle@cprfinance.com or faxed to 815-664-3330.
Representative:
Online Credit Application
Borrower/Lessee
Company Name
D/B/A
Fed Tax ID
State of Inc./Organization
D&B #
Address
City, State, & Zip
Telephone
Fax
Website
Contact Name
Contact Email
Business Type
Personal Info of Owners, Partners, or Officers
Name
Home Address
City, State, & Zip
Telephone
Social Security #
% Ownership
Name
Telephone
Home Address
Social Security #
City, State, & Zip
% Ownership
For Medical Transactions Only
Amount of Malpractice Carried
Avg. # Patients per Month
Practice/ Physician Specialty
Physician License #
Medical Groups You Belong To
Insurance Carriers Accepted
Business Banking (Checking & Savings) References
Bank Name
Address
Contact Name
Telephone
Account #
Bank Name
Address
Contact Name
Telephone
Account #
Business Trade References
Company Name
Contact Name
Telephone
Company Name
Contact Name
Telephone
Vendor and Equipment Information
Vendor Name
Description of Equipment
Amount to be Financed
Proposed Finance Terms
Number of Months
Products
I hereby represent all information is true, correct and complete. By placing my/our full name and date of birth in the indicated boxes you affirm your signature to be acceptable as a written signature. I/we authorize the release of any credit information, business or personal to be released to the submitter or its assigns. Submitter complies with section 326 of the US Patriot Act. This law mandates that submitter or its assigns request and verifies certain information about you and your company. A copy or fax of this authorization shall be valid as the original.
*If two Officers/Partners/Owners are listed, a second electronic signature is required
Officer Signature #1 (Type Authorizing Officer Name)
Date of Birth (mm/dd/yyyy)
Title
Date (mm/dd/yyyy)
Officer Signature #1 (Type Authorizing Officer Name)
Date of Birth (mm/dd/yyyy)
Title
Date (mm/dd/yyyy)
Prefunding % Required (If any)
Time In Business
Drivers Lic #
Drivers Lic #
Note: Vendor must be approved for any prefunding requests
