Credit Application

MedWORX Tech uses outside lending. We do not offer in house lending. MedWORX representatives cannot and will not quote rates, terms, guarantees or give approvals. All financing is subject to credit and financials. MedWORX representatives can only offer history of what typical rates and terms have looked like from past lending experience. Exact rates and terms can only be received through filling out and submitting a credit app. You should have loan approval and terms within 3 business days.

90 to 180 DAY DEFERRED LENDING PROGRAMS MAKE NO PAYMENTS UNTIL YOUR DEVICE IS PAYING FOR ITSELF

Typical terms:

TERM: 60 Months
INTEREST RATE: 5 — 10% OAC
DOWN PAYMENT: $500 — $1,500
MONTHLY PAYMENT FOR FIRST 3-6 MONTHS: $100
LOAN PAYMENT STARTING MONTH 4-7 FOR A $40,000 LOAN: $800 — $1000

Fill out and Submit the below Application:

Legal Company Name

D/B/A

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Person

First Name

Last Name

Fax

(###)

###

####

Phone

(###)

###

####

Federal EIN#

Time in Business Months/Years

Principal (1) Name

First Name

Last Name

% of Ownership 1

Social Security Number 1

Home Address 1

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone 1

(###)

###

####

Principal (2) Name

First Name

Last Name

% of Ownership 2

Social Security Number 2

Home Address 2

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone 2

(###)

###

####

Principal (3) Name

First Name

Last Name

% of Ownership 3

Social Security Number 3

Home Address 3

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone 3

(###)

###

####

Company Last Year's Approx. Gross Revenue

Company Average Bank Balance

Do you accept Credit Cards

Average Monthly Credit Card Volume

Device Type

Invoice Amount

Principal 1 E-Signature Confirmation

By checking this box you are confirming your signature.

Principal 1 Type Your Name to Sign

Delivery of this application bearing an E-Signature(s) shall have the same force and effect as if the application bore an inked original signature(s). I hereby certify that the information contained in this file is true and accurate. The applicant, owner(s) and guarantor (if any) authorize Gentox Medical Services or its designee(s) or assignee(s) to obtain any information it may request from any business or consumer reporting agencies or other sources that provide credit reports, account history information, credit and employment history or similar information; such authorization shall extend to update renew, or credit for reviewing and collecting the account.

First Name

Last Name

Today's Date

YYYY

Principal 2 E-Signature Confirmation

By checking this box you are confirming your signature

Principal 2 Type Your Name to Sign

First Name

Last Name

Today's Date

YYYY

Checkbox 2

By checking this box you are confirming your signature

Principal 3 Type Your Name to Sign

First Name

Last Name

Today's Date

YYYY