RC3 Financials

PO Box 15, Newport, ME 04953

1-866-626-5436

Email: razor@rc3financials.com

WHO WE ARE: We are RC3 Financials and we

have many years of financial experience.

www.rc3financials.com

WHAT IT COSTS: We do not charge to find you financing.

NO FEE!

WHAT WE DO: We realize that being a business owner that you are busy running your business and do not have time to find the financing it needs to grow and prosper. We FIND the financing you NEED.

ANY AMOUNT - ANY REASON

HOW YOU BENEFIT: More time to focus on your business!

Frequently Asked Questions (FAQ’s)

How Does It Work?

After we receive a completed application from you, we contact our network of lenders in search of financing for you

How Much Does It Cost?

We charge NO MONEY.

What If I Don’t Like The Financing?

Financing is subject to YOUR approval. You will be informed by a written proposal from the lender and given the opportunity to accept or not accept.

What is the Percentage Rate?

We do not quote percentage rates for the interest for the financing. This is done on a case by case basis and is different for each special scenario. It is specific to your business and to the purpose of the financing desired.

How Do I Get Started?

Simply fill out the one page application and fax it to 1-866-626-5436 or return it by United States Mail to RC3 Financials PO Box 15, Newport, ME 04953

Note: Additional documents may be required to find financing, in this case a RC3 Financials Loan Coordinator will be in touch.

APPLICATION SUMMARY

Total Amount Working Capital Requested $

Type Of Medical Specialty

Broker Name

Purpose Of Funds

PRACTICE INFORMATION

Practice Name

2006 Annual Gross Sales $

2005 Annual Gross Sales $

Street Address

City

State

Zip

Telephone Number ( ) -

Fax Number ( ) -

Contact Person

Legal Status PROPRIETORSHIP PARTNERSHIP CORPORATION OTHER __

Tax I.D. Number

Year Established

Year Licensed

Medical License Number #

OWNER INFORMATION

1

Name (First, MI, Last)

Title

% Of Ownership %

Street Address

Home Number ( ) -

Number ( ) -

City

State

Zip

Social Security Number - -

Date Of Birth

Email Address

2006 Annual Personal Income $

2005 Annual Personal Income $

2

Name (First, MI, Last)

Title

% Of Ownership %

Street Address

Home Number ( ) -

Number ( ) -

City

State

Zip

Social Security Number - -

Date Of Birth

Email Address

2005 Annual Personal Income $

2004 Annual Personal Income $

BANK INFORMATION

Bank Name

Contact Person

Phone Number ( ) -

Account Number

Average Balance Checking $

Average Balance Savings $

REQUIRED SIGNATURES

For the purpose of securing financing, I authorize all bank deposit, credit, trade references and borrowing information to be released by telephone or facsimile to RC3 Financials. and/or assigns.

Applicant Signature

Title

Date

RC3 Financials

1-866-626-5436

PERSONAL FINANCIAL STATEMENT

Section 1. Assets and Liabilities

Applicant Name:

SS #:

Date Of Birth:

Spouse Name:

SS #:

Date Of Birth:

Address, City, State Zip:

Home Phone Number:

Business Phone Number:

Have you ever filed for Bankruptcy (with in the last 10 years)?

Yes No

Do you have any Tax Liens?

Yes No

ASSETS

Value

LIABILITIES

Balance

Monthly Pmt

Checking & Savings (Personal):

$

Credit Cards, Charge Accounts & Lines of Credit:

$

$

Checking & Savings (Business):

$

Unpaid Taxes:

$

$

Stocks / Bonds / IRA / 401k:

$

Bank Loans (Personal):

$

$

Value Of Business (w/Equipment & Accounts receivable):

$

Business Loans:

$

$

Real Estate (Primary Residence):

$

Mortgage (Primary Residence) :

$

$

Real Estate (Other than primary residence):

$

Mortgage(s) (Other than primary residence):

$

$

Other Assets: ______________________

$

Other Loans:_______________________

$

$

TOTAL ASSETS

$

TOTAL LIABILITIES

$

TOTAL NET WORTH = (Total Assets ( - ) Total Liabilities)

$

I authorize RC3 Financials and/or its assigns to make inquiries as necessary to verify the accuracy of the statements made and to determine my credit worthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). These are made for the purpose of either obtaining a loan or guaranteeing a loan. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by U.S. Attorney General (Reference 18 U.S.C. 1001.) X

Signature

Date