Application - Golden Financial Solution

Medical Accounts Receivable Application

Please fill out the online application below. If you prefer a hard copy, please email us at info@goldenfinsolutions.com or call us at (949) 329-3696 . Thank you.

1GENERAL INFORMATION

2LIST OF PRINCIPALS / SHAREHOLDERS IN COMPANY

3OPPORTUNITY INFORMATION

4SERVICING REVIEW

5LEGAL REVIEW HAS THE COMPANY OR ANY OF ITS PRINCIPALS:

GENERAL INFORMATION

Company Legal Name *

Primary Physical Address

Mailing Address (if different than above)

Phone

Fax

Federal Tax ID Number

Company Inception (mo/year)

State of Incorporation

Primary treatment provided

Primary transaction type

Does the Company currently operate under any other names? (If yes, please list)

Has the Company operated under any other names in the past? (If yes, please list)

Number of Locations

Contact Person Name *

Contact Person Title *

Contact Person Phone

Contact Person Email *

Phone