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Fonar Financial Services

FONAR Acceptance Corporation
Credit Application

CORPORATE INFORMATION
MRI Equipment:
Professional corporation operating MRI scanner (required)
State of Incorporation:
Federal ID#:  
Stockholder of Record:
Ownership %
Stockholder of Record:
Ownership %
Full Corporate Address:  

Street

(required)
City
(required)

State

  (required)
Zip
(required)

Telephone

(required)
Fax

Email

(required
   
MAJORITY OWNER PERSONAL INFORMATION
Home Address:
 
Name
Street
City
State
Zip

Professional Mailing Address

 
Street
City
State
Zip
State(s) in which I am licensed
Social Security Number
Medical License #
Additional Information

By clicking the "Submit Credit Application" below, I certify that I have read the Credit Release And Acknowledgement and I authorize Fonar Acceptance Corp, its affiliates or assigns, to access business or consumer credit bureau information.


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