Gemino Healthcare Finance

Vision. Growth. Strength.

Contact Us

Email	info@gemino.com
Phone	770.321.4033 x 3

Online Application

Please fill out the form below to submit an electronic loan application.

Borrower Information

Type of Business: *

What is your primary field of business?

Medicare/Medicaid Certified: *

yes

no

Contact Name: *

The person to contact about this application.

Borrower's Name: *

Full name of borrower.

Borrower's Trade Name:

If applicable.

Corporate Street Address: *

City: *

State: * select...ALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY

Zip Code: *

Phone Number: *

Please use the format: 123-456-7890.

Fax Number:

Please use the format: 123-456-7890.

Tax ID Number: *

Please use the format: 12-3456789 for EIN or 123-45-6789 for SSN.

Years in Business: *

Number of Employees: *

Corporate Structure / Ownership

Type of Business: * select...CorporationLLCPartnershipSole ProprietorshipOther

State of Incorporation: * select...NoneALAKASAZARCACOCTDEDCFMFLGAGUHIIDILINIAKSKYLAMEMHMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHOKORPWPAPRRISCSDTNTXUTVTVIVAWAWVWIWY

Only select if incorporated.

Borrower's Owner: *

Senior Management Background: *

Description of Business: *

Initial Facility Structure

Amount Requested: *

Use of Proceeds: *

Mortgage Term: *

Revenue / Accounts Receivables Breakdown

Any existing issues with accounts receivable?: *

yes

no

Any material amounts due to Medicare / Medicaid?: *

yes

no

If yes on either, please explain:

Describe approximate percentage of revenue or accounts receivable by classes and amount as noted below:

Group Insurance (Percentage of Revenue): *

Group Insurance (Amount): *

Blue Cross / Blue Shield (Percentage of Revenue): *

Blue Cross / Blue Shield (Amount): *

HMO / PPO (Percentage of Revenue): *

HMO / PPO (Amount): *

Medicare / Medicaid (Percentage of Revenue): *

Medicare / Medicaid (Amount): *

Private Pay (Percentage of Revenue): *

Private Pay (Amount): *

Worker's Compensation (Percentage of Revenue): *

Worker's Compensation (Amount): *

Other (Percentage of Revenue): *

Other (Amount): *

Legal Issues

Answer each of the following questions by marking the appropriate response. Any "yes" response will require further explanation. Provide details in next section.

Do you have any liens against your accounts receivable?: *

yes

no

Do the principals or borrower have any pending or current litigation?: *

yes

no

Have the principals or borrower ever filed for protection under U.S. Bankruptcy laws?: *

yes

no

Do existing debt instruments prohibit pledging accounts receivables?: *

yes

no

If yes, please attach copy in "Attachments" section at the end of this application.

Are there any defaults on current debt?: *

yes

no

Legal Explanations (If Necessary):

Questions:

Attachments

Please attach copies of the following information (file formats: doc, xls, pdf, zip | max file size: 10MB):

Three years of historical consolidated/consolidating financial statements:

Year-to-date financial statements:

Most recent accounts receivable aging report (by days and payor class):

Revenue and Collections by payor for past 12 months:

Census/visit information (if applicable):

Existing debt instruments (if applicable):

Corporate / Organization structure (if available):

Accounts receivable aging (if available):

© 2007 Gemino^® Healthcare Finance, Incorporated. All rights reserved. Admin Login