Equipment and Payment Information
Briefly describe the equipment you wish to finance *
Preferred Term Length *
* Multi Radiance Medical will not store your Social Security information from this application and will be sent directly NCMIC electronocally.
I hereby authorize the release of business and/or personal credit information to Multi Radiance Medical it's affiliates of assignee (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 hereby represent all information is true, correct and complete. A photo static and/or facsimile 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 we may ask for your name, address, date of birth, social security number, and other information that will allow us to We may also require that you furnish 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 Finance Corporation and the equipment vendor/ broker you selected are separate companies, are not agents of one another and have no authority to bind one another to financial or other contractual obligations.
Digital signature *
To agree on the trems as listed above and submit your application to NCMIC, please sign digitally by adding your initials here.