Working Capital Request Form

Please fill in the information below. Information marked with an * is required to submit your request.

Amount Requested
  • $   (Must be between $5,000 and $20,000.)
Practice Information
  • (Legal business name and DBA)
 
  • (as xxx-xxx-xxxx)
  • (as xxx-xxx-xxxx)
  •  
  • Your e-mail address will never be shared or sold. It will be used to send you important notices.
years
$
$
Personal Information
  • (as xxx-xx-xxxx)
 
  • (as xxx-xxx-xxxx)
  • (as xxx-xxx-xxxx)
(years)  
  •  
Authorization and Disclosure

I hereby authorize the release of business and/or personal credit information to NCMIC Finance Corporation (NCMIC), its affiliates or assignees (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. Additionally if my application is not approved by NCMIC, I hereby authorize the release of my application without notice, to any other potential lending sources not related to NCMIC Finance Corporation for consideration of approval of credit. I hereby represent all information is true, correct and complete. A photo static, facsimile, or other electronic copy of this authorization shall be valid as the original. The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applications 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 with NCMIC we will ask for your name, address, date of birth, social security number, and other information that will allow NCMIC to identify you. We may also require that you furnish NCMIC with 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. 

* I have read the Authorization and Disclosure and: