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1. Company Information

Business Legal Name *

Classification *

Time in Business *

Main Phone *

Fax

DBA Business Name

Number of Employees

Physical Street Address *

Zip Code *

Federal Tax ID#

Last Year's Sales

Website

Is physical and billing address different? Yes No

Industry Type

Business Location

2. Financial Information

Type of Equipment You Want *

Item Number of Equipment You Want

Current Credit Card Processor

Average Monthly Credit Card Volume

Amount Requested *

Total Estimated Equipment Cost

Equipment To Be Financed or Leased

Loan Term Preferred One (1) year or less More than 1 year

Do You Already Have a Current Working Capital Loan? Yes No

Cash Towards Down Payment

Bank Name

Bank Phone Number

Do You Have a Co-signer? * Yes No

3. Principal Information (Personal Information of Proprietors, Partners or Major Shareholders)

Owner 1

First Name *

Middle Name

Last Name *

Title

Home Address *

Zip Code *

Ownership % of Company *

Home Phone

Cell Phone *

Date of Birth *

SSN *

Home Ownership *

Your Approximate Credit Score

Email *

Clear Signature --/--/---- signature date

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Owner Signature - Click above

Confirm Signature Clear Signature

4. Other Information

Any Judgments/Liens? * Yes No

Any Open Bankruptcies? * Yes No

Is This a Home Based Business? * Yes No

Is Your Business Seasonal? * Yes No

Business Trade Reference #1

Phone

Business Trade Reference #2

Phone

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601-749-8424

Equipment Funding Application

1. Company Information

2. Financial Information

Co-signer Information

3. Principal Information (Personal Information of Proprietors, Partners or Major Shareholders)

Owner 1

Owner 2

Owner 3

Owner 4

4. Other Information