QuickSleeper Leasing

Leasing is available to make your purchase of the QuickSleeper affordable. Lease the QuickSleeper today and start delivering PainLess LA tomorrow. Lease rates range between 180 to 250 per month depending on terms. Please complete the form below to apply.

BUSINESS INFORMATION

Legal business name(Required)

Practitioner’s name(Required)

Professional address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Premises

Own premises

Rent premises

Remaining premises lease term

Gross monthly billings(Required)

Monthly expenses(Required)

PERSONAL INFORMATION

Date of Birth(Required)

Grad year and degree granting university(Required)

Years in Private practice(Required)

Home address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Have you ever declared bankruptcy or had a judgment rendered against you?(Required)

Yes

Are you party to any lawsuits or claims?(Required)

Yes

Do you have any tax arrears (income, GST, PST, property, business)?(Required)

Yes

The undersigned certifies this above information to be true and correct.
Note: Providing a SIN# is optional. Please note that it may assist in running a credit check.

Additional comments as applicable

Consent respecting personal information:(Required)

By signing this Application, each of you, being the parties signing (including all lessees and all guarantors) authorize and entitle MediCapital Inc. and its assignee, lender, funding source, agent or nominee (collectively “us or “we””) to collect, use,hold and disclose the personal information provided by, or that we collect about, you in connection with your application and the administration of your lease (“ your Personal Information”) to assess your ability to obtain and continue to be eligible for your lease and to valuate your current and continuing ability to meet your financial obligations. This use includes disclosing and exchanging your Personal Information on an on-going basis with credit bureaus, credit reporting agencies and financial institutions or their agents, or to service providers for the purposes described above, to help prevent and protect you and us from fraud and to protect the integrity of the credit-granting system. This use, disclosure and exchange of your Personal Information will continue as long as your lease(s) is (are) outstanding.

QuickSleeper Leasing

BUSINESS INFORMATION

PERSONAL INFORMATION

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