I. Background |
|
| Date | |
| Business Name | |
| Business Address | |
| Phone | |
| Fax | |
| Own or Lease | Own Lease (choose one) |
| Name of leasing agent | |
| Phone | |
| E.I.N.# | |
| Current Business Type | |
| Date Established | |
| Type of Company | Corporation Partnership Sole Proprietorship |
| Business Principles #1 | |
| Name | |
| Title | |
| SSN | |
| Address | |
| Business Principles #2 | |
| Name | |
| Title | |
| SSN | |
| Address | |
| Business Principle #3 | |
| Name | |
| Title | |
| SSN | |
| Address | |
| Number of employees | |
II. Credit |
|
| Trade References | (Name and phone number of 3 suppliers of products regularly purchased) |
| Loan Information | |
| Lender | |
| Phone | |
| Balance | |
| Address | |
| Contact Name | |
| Type of loan | |
| Bank of Deposit | |
| Account Number: | |
| By signing below I/we hereby certify that all information on this application is true and complete. I/we authorize you to investigate my/our credit record (both business and personal) and check the information I/we have prepared. | |
III. Compliance |
|
| In conjunction with our application and as an inducement for you to approve this application, the undersigned hereby answers the following questions: | |
| #1. Is your company or any of its officers currently a defendant in any legal action? | |
| Yes No | |
| #2.IF YES ABOVE: Is your company or any of its officers or stockholders (owners) presently under indictment or ever been convicted of a felony? | |
| Yes No | |
| If yes, please explain | |
| #3. Is your company or any of its officers or stockholders (owners) presently charged with or ever been convicted of any law relating to the business? (felony or misdemeanor) | |
| Yes N | |
| If yes, please explain | |
| #4. Is your company under investigation or has it in the last five years been investigated by any federal, state, or local government body for possible violation of law in conduct with this or any other company? | |
| Yes No | |
| If yes, please explain | |
| #5. Has your contractors license been revoked or suspended within the last five years? (Select) (yes or no) If yes, please explain | |
| Yes No | |
| If yes, please explain | |
| #6. Has your company ever been charged with an unfair or deceptive practice by the U.S. Federal Trade Commission or is there presently any investigation of your business activities by that or any other agency? (Select) (yes or no) If yes, please explain: | |
| Yes No | |
| If yes, please explain | |
IV. Insurance |
|
| Insurance Company | |
| Name | |
| Agent | |
| Address | Phone |
| Amount of Liability Coverage | |
| Company | |
| Worker's Compensation Carrier | |
V. Financial |
|
| Do you utilize a Certified Public Accountant? (yes or no) Please list name and phone number of CPA. | |
| Yes No | |
| Who prepares your financial statements/tax returns? (Name and Number) | |
Signatures |
|
| Name | |
| Title | |
| Date | |
| Signature | |
| Name | |
| Title | |
| Date | |
| Signature | |
You can either print this document and fill out by pen, and then fax to: 502-690-8183 (click here for fax cover sheet) or you can fill out the entire document except the signature lines and submit.
Contact Don Shelby at our offices at 502-690-8183, or at 502-523-2369 if you have any questions