NeuroDyne

Simple Lease Application
It is as easy as 1-2-3
(This form is on our secure server.)

Please provide the following information to qualify for a lease. We will get back to you as soon as possible. Also, feel free to call us at 1-800-9NEUMED or 617-234-1100, if you have any questions.

1- Please provide the following contact information:

Name	Title
Business Name
*Yrs. in Business*
*Business Address*
*City, State, Zip*
Work Phone	FAX
E-mail
Bank Name
Bank Phone#	*Acc #*
*Business Tax ID*	*SS#*

2- Please provide the following product information:

Product Name:

Above lease rates are based on 60 month lease. You own equipment at the end of the lease.
Our lease allows you to prepay outstanding amount any time without any pre-payment penalties. Giving you the flexibility of lease now and pay-off remaining balance later.
Please select one of the following for other lease periods.

24 Months 36 Months 60 Months (60 Months gives the lowest payment.)

Submit this form now or simply print and fax to 1-877-9NEUROFX or 617-234-1108

NeuroDyne Medical, Corp.
52 New Street, Cambridge, MA 02138 USA
Ph# 1-800-9NEUMED or 617-234-1100
Fx# 1-877-NEUROFX or 617-234-1108
Revised: January 07, 2004