EQUIPMENT PURCHASE APPLICATION

By clicking "Submit", on behalf of themselves and the applicant, the applicant and the Owners/Partners/Members/Guarantors agree as follows: They certify that the information provided in this application is complete and accurate. The undersigned individual as principal of and/or guarantor for the applicant, authorizes Synergy Medsales, its designee, lenders/funders, assigns or potential assigns, to review his/her personal credit profile and related documentation in considering this application and for the purpose of the update, renewal, or extension of credit to the applicant or the collection of any resultant accounts. The authorization will be ongoing and relate not only to the evaluation and/or extension of the business credit extended, but also for the purpose of reviewing the account. By the execution of the application, I/We warrant that the information submitted herein is true and correct and hereby authorize that any bank, lending institution, supplier, person or consumer reporting agency should comply and furnish any information Synergy Medsales deems necessary in connection with this application. Any and all disputes must be heard in the county of Dallas, state of Texas. Further, I/We warrant it is understood that Synergy Medsales reserves the right to reverse any credit decision if the information contained herein is found to be incorrect, and I/We will indemnify Synergy Medsales for any and all costs incurred with this application for credit including any cost incurred in the placement or reservation of the intended leased equipment based on the information contained herein.