Application For Practice
Please fill in all fields
For questions or issues, call us at 678-905-9566 or email
sales@curaefinance.com.
- Every field is required. A voided check for the business is also required.
- If the Type of Ownership = Sole Proprietor or Other, then the Principal Owner’s SSN, home address, and DOB is required.
- If the practice has more than one location, the applicant is required to list the details on the additional locations after the main.
- If the practice has more than one location and individual location billing is selected, a voided check must be uploaded for each location.
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Business Information
Legal Business Name*
Doing Business As (if different)
Name of Primary Contact*
Title*
Corporate Address*
Corporate City*
Corporate State*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Corporate Zip*
Business Phone*
Email*
Business Website*
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