DENTAL PRACTICE INFORMATION SHEET	
Dentist Information	

Type of Entity (check One)                        □   Corporation                                        □   Limited Liability Company                                   □   Partnership                                            □   Limited Partnership
 
□   Limited Liability Partnership              □    Professional Limited Liability Company                          State of Inc/Org:   _________________________                      Yearly Gross Sales $:__________________________

 ADVANCE AMOUNT REQUESTED:   ______________________________________________         Type of Practice:  _____________________________________________________
	
Business Legal Name	D/B/A	Tax ID (or SS# for Sole Prop)	
Business Physical Address	City, State, Zip	
Business Mailing/Billing Address (if different than physical address)	City, State, Zip	
Days of Operation (circle)
Monday       Tuesday       Wednesday       Thursday      Friday      Saturday     Sunday	Please list office locations
	
Contact Name	Title	Number of Partners or Physicians in Practice	
Business Phone	Business Fax 	Email Address	Date Business Started (mm/yy)	
Business Mailing/Billing Address (if different than physical address)	Total Annual Revenues (inc  all payments cash, credit card, check, insurance, etc.)	
Malpractice Insurance in Good Standing?	Any known pending or existing litigation?	
Own/Lease Office Loc.	Lease Start Date	Lease Term	Monthly Rent/Mtg	Type of building	Sq. Ft (approx)	
If owned, is your facility currently for sale?	If owned, do you intend to sell your facility within the next 12 months?	
Landlord/Mortgage Company	Contact Name	Phone Number	Fax	
Owner/Principal/Partner No. 1	
Name	Percentage Ownership	Social Security Number	
Date of Birth	Title	Home Phone #	Cell Phone #	
Residence Address	City, State, Zip	
Owner/Principal No. 2	
Name	Percentage Ownership	Social Security Number	
Date of Birth	Title	Home Phone #	Cell Phone #	
Residence Address	City, State, Zip	
Electronic Transaction Information	
Total Monthly Credit Card Sales (Visa.MC, Discover, Amex, etc)	Average Ticket Size 	Average # of Transactions per Day   # of Batches Per Week	
Total Monthly Check Volume	Average Check Size	Average # of Checks per Month        # of Batches Per Week	
Total Monthly Insurance or Third Party Receivable Receipts	Average Claim/Transaction Size	Average Transactions per Month      # of Batches Per Week	
Aging of Accounts Receivables (closest approximations)
0-30 days ___________%     31-60 days ____________%     61-90 days ____________%     91-120days ____________%     121-150 days ___________%     151-180 days ___________%     >180 days ____________%	
Applicant, named above, attests that the information provided on this form is accurate and complete, that providing the information to BRT Financial, Inc. and/or its assignees, does not constitute an application for credit, and that submitting the information does not obligate BRT Financial, Inc. and/or its assignees to fund an advance.  In addition, Applicant authorizes BRT Financial, Inc. and/or its assignees, or designee(s) to obtain an investigative report from credit bureaus or credit agencies, and also to investigate the vendor references and any other references or information given on this application or any other documents submitted by applicant for the purpose of obtaining funding.  	
Principal #1	Signature	Date:	% Ownership	
Principal #2	Signature	Date:	% Ownership	
Principal #3	Signature	Date:	% Ownership	

BRT Financial, Inc.
Fax Information Sheet and 4 Months Bank Statements to (904-513-9229)