REFERRING PARTNER INFORMATION (Part 1 of 7)

Referring Partner Company Name

Referring Partner Full Name

Referring Partner Phone #

Referring Partner Email

GENERAL INFORMATION (Part 2 of 7)

Provider Company Name

Provider Fictitious Name or DBA

Street Address

City

State

Zip

Tax ID #

License #

Contact Person / Administrator

Phone

Fax

Email

COMPANY OWNERSHIP INFO (Part 3 of 7)

Owner #1

Name

Phone

Fax

Email

Owner #2

Name

Phone

Fax

Email

Owner #3

Name

Phone

Fax

Email

Owner #4

Name

Phone

Fax

Email

COMPANY INFO (Part 4 of 7)

What type of facility is it? (Physician, MRI, Hospital, DME, etc…)

How long has the company been operating?

Please provide brief history and overview of the company

Why is the company seeking financing and/or interested in selling its receivables?

How much money are you seeking?

Has the company previously received financing or attempted to sell its receivables? If so, please provide reason and outcome.

Are there any current liens against the accounts receivable? If so, please state whether it's a bank, IRS or other lien and for how much.
 NONE BANK IRS OTHER

Does the company use a 3rd party billing/collection company? If so, how long has the contract been in place?

What is the monthly gross billed amount average over the last two years? If not applicable, write N/A

What is the company's monthly operating expense?

Where does the company bank? (Chase, Wells Fargo, etc…)

How many W2 employees does the company have?

How many 1099 contractors does the company have?

How many locations does the company operate from?

How does the company generate its business, i.e. referral sources?

Has the company or any of its principals ever been involved in bankruptcy proceedings? If yes, please explain.
 YES NO

Are there any claims, actions, suits or judgments current or pending against the company or its principals? If yes, please explain.
 YES NO

Have any of the principles, owners, managers, or operators of the company ever been charged or convicted of any crimes? If yes, please explain.
 YES NO

Does the company do its own payroll? If not, is there a 3rd party?
 YES NO

Are Payroll taxes current? If not, what's the delinquent amount?
 YES NO

Are Federal taxes current? If not, what's the delinquent amount?
 YES NO

Are State taxes current? If not, what's the delinquent amount?
 YES NO

Please provide any additional information you deem necessary for evaluation of your request for financing / sale of receivables.

REVENUE BREAKDOWN (Part 5 of 7)

REVENUE BREAKDOWN PERCENTAGE (%)

No-Fault/PIP

Worker's Comp

Medicare/Medicaid

Commercial

Lien/LOP

Self Pay

Other

COMPLETED BY (Part 6 of 7)

By signing below or submitting your name electronically, the Borrower, its owners/principals, or representatives filling out this application: (1) certify that all information and documents submitted in connection with this Application is true, correct and complete; and (2) authorize Alleon Capital Partners, LLC and its affiliates to receive credit reports and any other background information regarding the Borrower and its owners/principals from third parties, to verify any information provided on this application.

App Completed by

Title

ADDITIONAL INFO (Part 7 of 7)

Have you spoken to an Alleon representative? If so please specify

Additional Notes