|
3520 Patrick Street, Suite 216, Lake Charles, LA 70605 Phone: 337-474-2352 Fax: 337-478-3697 |
|
(Please Print or Type All Information) ========================================================================== Business Information Name of Business: ________________________________________________________ Doing Business As: _______________________________________________________ Business Type: __ Sole Proprietorship __ Partnership __ LLC __ Corporation Date Incorporated: _____________ Federal ID No: __________________________ Years Under Same Ownership: ______ Years of Related Experience: ______ Phone Number: _______________________ Fax Number: ________________________ Describe Business: _______________________________________________________ Physical Address: _______________________________________________________ Mailing Address: _______________________________________________________ Previous Address: _______________________________________________________ ========================================================================== Current Residence Home Status: __ Buying __ Renting __ Paid For Years at Residence: _____ Mortgage Company: ________________________________________________________ Amount of Monthly Payment: _________ Phone Number: _______________________ ========================================================================== Bank References - 2 Year History Required 1. Bank Name: __________________________________ Date Opened: ____________ Account No: _______________________________ Phone: _______________________ 2. Bank Name: __________________________________ Date Opened: ____________ Account No: _______________________________ Phone: _______________________ ========================================================================== Trade and Finance References 1. Reference: _____________________________________ Years of Credit: _____ Contact: __________________________________ Phone: _______________________ 2. Reference: _____________________________________ Years of Credit: _____ Contact: __________________________________ Phone: _______________________ 3. Reference: _____________________________________ Years of Credit: _____ Contact: __________________________________ Phone: _______________________ ========================================================================== Equipment Vendor Vendor: _________________________________ Contact: _______________________ Address: __________________________________ Phone: _______________________ ========================================================================== Equipment to be Leased or Financed Describe Equipment: ______________________________________________________ Funding: ___ Leasing is Requested ___ Financing is Requested ___ Undecided Term: ____ Months - Buy Out: ___ $1.00 ___ 10% or Other: _________________ Total Equipment Cost - Do Not Include Without Taxes: _____________ ========================================================================== This application is given for the purpose of obtaining credit. I hereby certify under penalty of law that the foregoing is a true and complete statement of my/our financial condition. In the event of any material change in my/our financial condition, I will notify US Financial Group immediately in writing. I understand that individual credit histories may be a determining factor in the evaluation of this application and I grant US Financial Group permission to obtain a personal credit report on all of the individuals that are listed above. Date: _________________ Signature: _______________________________________ |