(3) Submit Your MEDICAL, DENTAL or VETERINARY Financing REQUEST Here.

Please complete the information below. It is important that you provide all key information for us to get back to you ASAP. "However if you would like to do this over phone, please contact us [click "Contact Us" in menu above] or call +1 954 667 7379. You can Email us [aza@mmpres.com] to arrange a telephone conversation. Thanks and speak with you soon!"

" || Folks, accurate information below determines Initial Qualification. Please do the needful? || " MCL
PERSONAL CONTACT DETAILS of Medical/Dental/Veterinary Professional
Ref. You want us to use when we contact you :
Your First Name :
Your Last Name :
Are you the Borrower? - Yes/No :	No     Yes
If No - Borrower (Medical Professional's) Full Name : :
Mobile  :
Phone :
Fax :
Email Address :
Address :
City :
State :	Select State/Province Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Iowa Indiana Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Washington, D.C. --------------------- Alberta British Columbia Manitoba Newfoundland New Brunswick Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
Zip Code :
INITIAL FINANCING REQUEST INFORMATION
Financing Amount Requested  :
Funds to be Used for - Select all applicable :	Practice Acquisition Practice Equipment Financing/Leasing Practice Real Estate Financing Practice Consolidation (debt) Practice Construction/Expansion/Relocation/Remodel Add Location Practice Startup Practice Working Capital
CURRENT PRACTICE INFORMATION - If Applicable
Practice Name :
Practice First Started (Date or Year) :
Practice Ownership (LLC, Corp, Prtnr, PLLC , Other) :	N/A     LLC     Corp     Prtnr     PLLC      Other
When was the Practice First Incorporated as Legal Entity (Date or Year) :
Practice Property Owned or Rented :	N/A     Owned     Rented
Property Address :
Property City :
Property State :
Property ZIP :
If applicable - Do you have more than one Practice? - No/Yes :	N/A     No     Yes
Other Comments or Information
Other Comments or Information :
|| Other Information will be required and we'll get in touch ASAP || - Thanks for your Time, and speak with you soon!
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Note: We are originators (Hedge & Commercial Funds),lenders and work with Chosen Lenders ONLY, we will analyse the information from a lenders perspective. We assist a qualified borrower-buyer to purchase distressed assets, buy-outs, partnership share purchase, and other related Balance Sheet liquidity but, they will be analyzed as if a lender wants to invest in it! Sorry, but we are governed by Prudence!