Apply for Financing & More

Application

Please complete this application and we will contact you shortly to schedule a one-on-one discussion with one of our senior advisors to discuss your business and our funding options:

Our goal is to help you and your business, Grow with Us!

1 Business Information

2 Principal Owner #1 Personal Information

3 Owner #2 Personal Information

4 Financial Information

Business Information
Thank you for contacting us! Prefer to apply online for a no-cost/no-obligation quote? Continue your application process below!
Legal Business Name*
DBA Name*
Business Phone*
Business Fax
Email*
Business Type*
Address*
Street Address Address Line 2 City State ZIP Code
Owned Business Since*
MM
DD
YYYY
Business Open Date*
MM
DD
YYYY
Own or Lease Facility
Lease Start Date
MM
DD
YYYY
Lease Term
Rent or Mortgage Payment
Days of Operation
Number of Employees
Please enter a number greater than or equal to 0.
Number of Locations*
Please enter a number greater than or equal to 1.
Landlord/Mortgage Company Name and Contact Information
Briefly Describe Business*
Website

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Principal Owner #1 Personal Information
Name*
Prefix First Middle Last
Email Address of Applicant*
Cell Phone*
Home Phone
Home Address*
Street Address Address Line 2 City State ZIP Code
Social Security Number*
Date of Birth*
MM
DD
YYYY
Percentage of business ownership*
Please enter a number from 0 to 100.

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Owner #2 Personal Information
Name
Prefix First Middle Last
Email Address of Applicant
Cell Phone
Home Phone
Home Address
Street Address Address Line 2 City State ZIP Code
Social Security Number
Date of Birth
MM
DD
YYYY
Percentage of business ownership
Please enter a number from 0 to 100.

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Financial Information
Federal Tax ID*
Types of Electronic Payments Accepted
Average Monthly Sales From Electronic Payments
Total Monthly Sales (All payment types)*
Billing Company
Is your Business for Sale?*
Do you have Federal or State Tax Liens?*
Federal or State Tax Liens Explanation*
Have you ever filed for Bankruptcy?*
Bankruptcy Explanation*
Do you have any Outstanding Financing?*
Names and Balances*
Requested Financing Amount*
Intended Use of Proceeds*
Bank Statements
Upload your six most recent bank statements.
This step is required to process an application, however if you experience any issues with uploading, you can submit the application and send documents separately to submissions@healthgrowthcapital.com
Drop files here or

Accepted file types: jpg, jpeg, gif, tif, png, pdf, tiff.
I agree that the information provided herein is true and correct, and give HealthGrowth Capital permission to perform due diligence with the submission of this application.*
- Agree
Signature*
Signature (Co-Owner/Applicant)*
Referral
If you were referred by someone or one of our partners, please enter their name here.
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

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