Legal Name of Pharmacy:
Trade Name (or d/b/a):
Street Address:
City:
County:
State:
Zip Code:

Pharmacy Contact Information:

Main Contact Person:
Phone Number:

Fax Number:

Email:

Pharmacy Business Information:
Tax ID Number:

Business Type: Please Select One Below
---CorporationProprietorshipPartnershipLimited Liability CorporationOther

Years in Business:
Name & Title of Document Signer:

Name & Title of Officer Authorizing Document Signer:

Owner(s) Information:
Total Numbers of Owners:

Owner 1:
Name:
Social Security Number:
Percentage of Ownership:

Owner 2:
Name:
Social Security Number:
Percentage of Ownership:

Owner 3:
Name:
Social Security Number:
Percentage of Ownership:

Owner 4:
Name:
Social Security Number:
Percentage of Ownership:

Bank Information:
Bank Reference:
Account Number:
Account Type:
---Business CheckingBusiness SavingsPersonal CheckingPersonal CheckingOther
Contact Name:
Contact Phone:

Type of Pharmacy Operation:
Retail: Not ApplicableIndependentIndependent/ClosedSmall Chain (50-20)Grocery
Institutional: ---Not ApplicableClinicClosed DoorMail Order OnlyHospital - OutpatientUniversityOther

1) Identify average number of prescriptions filled per day?

2) Number of pharmacies owned:

3) Number of locations per corporate entity:

4) Identify names of pharmacies owned:

5) How long has each pharmacy been owned under current ownership?

6) Does pharmacy services long term care facilities? YesNo

If yes what % of business from Long Term Care facilities?

7) Identify annual gross revenues per pharmacy owned:

8) Identify any pending litigation or adverse financial condition:

Business Purpose: You, the credit applicant, certify to us that you are applying for credit for a business purpose, and not for personal, family, or household purposes, and that the information you provided is true and correct.

ECOA Notice: If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact the Credit Disclosure Administrator, Americorp Financial, LLC, 877 S. Adams, Birmingham, MI 48009, phone (248) 723-4500, within 60 days from that date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement. The Federal Equal Opportunity Act prohibits creditors form 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 part of the applicant’s income derives from any public assistance program; or because the applicant has, in good faith, exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington DC 20580.

APPLICANT AGREES AND ACKNOWLEDGES THAT ANY ACCEPTANCE OF THIS APPLICATION OR SUBSEQUENT LEASE MAY BE REVOKED AND ANY DELIVERY SUSPENDED IF A MATERIAL ADVERSE FINANCIAL CONDITION IS IDENTIFIED BEFORE DELIVERY. I AUTHORIZE YOU TO OBTAIN PERSONAL CREDIT INFORMATION ON ALL PRINCIPALS AND/OR GUARANTORS LISTED ABOVE FROM ANY REPORTING AGENCY USED BY AMERICORP FINANCIAL, LLC OR IT'S AFFILIATES. PLEASE RESPOND TO AMERICORP FINANCIAL’S TELEPHONE REQUEST OR BY FAX IF YOU NEED WRITTEN PROOF OF THE REQUEST AND OUR RELEASE.

THIS IS YOUR WRITTEN AUTHORIZATION TO RELEASE THE INFORMATION REQUESTED.