Application – Praxsyn Capital

Step 1

Step 2

Step 3

Step 4

Step 5

Step 6

Step 7

Referring Partner Information (Part 1 of 7)

Referring Partner Company Name*

Referring Partner Full Name*

Referring Partner Phone Number*

Referring Partner Email Address*

General Information (Part 2 of 7)

Provider Company Name*

Provider Fictitious Name or DBA

Street Address*

City*

State*

Zip Code*

Tax ID #*

License #*

Contact Person / Administrator*

Phone*

Fax

Email*

Company Ownership Information (Part 3 of 7)

Owner #1 Name*

Phone*

Fax

Email*

Owner #2 Name (If Applicable)

If there is only 1 owner, please proceed to the next step

Phone

Fax

Owner #3 Name (If Applicable)

If there is only 1 owner, please proceed to the next step

Phone

Fax

Owner #4 Name (If Applicable)

If there is only 1 owner, please proceed to the next step

Phone

Fax

Revenue Breakdown (Part 5 of 7) Please breakdown your revenue by percentage (I.E. 25%, 50%, 75%)

No-Fault / PIP

Worker's Comp

Medicare / Medicaid

Commercial

Lien / LOP

Self Pay

Other

Completed By

BY SIGNING BELOW OR SUBMITTING YOUR NAME ELECTRONICALLY, THE BORROWER, ITS OWNERS/PRINCIPALS, OR REPRESENTATIVES FILLING OUT THIS APPLICATION: (1) CERTIFY THAT ALL INFORMATION AND DOCUMENTS SUBMITTED IN CONNECTION WITH THIS APPLICATION IS TRUE, CORRECT AND COMPLETE; AND (2) AUTHORIZE ALLEON CAPITAL PARTNERS, LLC AND ITS AFFILIATES TO RECEIVE CREDIT REPORTS AND ANY OTHER BACKGROUND INFORMATION REGARDING THE BORROWER AND ITS OWNERS/PRINCIPALS FROM THIRD PARTIES, TO VERIFY ANY INFORMATION PROVIDED ON THIS APPLICATION.

App Completed By*

First Name

Last Name

Company Title

Additional Info (Part 7 of 7)

Have you spoken to one of our representatives previously?*

This field should be left blank