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Become A Partner

In order to provide a financing program that continually meets the needs of our Partners and their customers, Provider Capital Group requires that all merchants complete the following Application Form. All information collected kept is strictly confidential.

Business Contact Information

* Name of business:
* Name of applicant:
* Telephone:
* Facsimile:
* Address:
* City:
* Province:
* Postal Code:
* Email:
Website address:
(if applicable)

Business Ownership Information

* Owner's name:
Date of birth(mm/dd/yyyy):
* Driver's licence:
* Residential address:
* City:
* Province:
* Postal code:

Company Profile

  1. * Briefly describe the nature of your business
  2. * In what year was your company established?
  3. * How long under current control?
  4. * Number of Employees?
  5. * Monthly sales volumes?
  6. * Estimated monthly financing volumes?

Products / Services

  1. * What is the average sale price of each product/service? (please include taxes in the calculation)
  2. * What is the average term per contract?
  3. * Is there a warranty attached to the product/service?
  4. * Who is your current warranty provider?
  5. * Is your office equipped with a PC and Internet Access?   Yes  No
  6. * Does your company use Direct Sales contracts?   Yes  No

Financing Options

  1. * Do you currently have financing relationships with any other financial institution or financing company for any of your equipment?   Yes  No
  2. If yes, which financial institution or financing company?
  3. Do you expect to offer financing promotions ?    Yes  No
  4. If yes, then what time of the year ?
  5. * I have the authority to bind the above company.    Yes  No

Provider Capital Group, should it accept this Application, intends to provide access to its Finance program and technology to the above identified organization (hereinafter called the “MERCHANT”); The MERCHANT will be required to enter into a formal Merchant Agreement before access to the Provider Capital Group finance program will be granted.

     I, the applicant, have read the above statement and agree to the terms as outlined.

     I, the applicant certify that the information provided in the application is true and correct to the best of my knowledge.

* For security purposes, please enter the code below in the field to the right: