Medical Receivables Factoring

Please fill in the blanks below. All fields are required.

CONTACT INFORMATION
Associate ID Number (if applicable)
Associate Name (if applicable)
TCF Locator Email Address (if applicable)
The person completing this form is
First & last name:
Contact's email address
Phone
Which search engine did you use to find us?
Which keywords did you use for your search?
BUSINESS INFORMATION
Name of Medical Facility
Current Accounts Receivable balance
How much would you like to fund?
How long has your company been in business?
OTHER COMMENTS
Any additional information you think we should know