GPD

Download the Application Form in PDF format

Download the Application Form in DOC format

SECTION A APPLICATION INFORMATION

Complete Legal Name

Street Address

City

State

Zip

Mailing Address

City

State

Zip

Phone:

Fax:

Cell #

E-mail Address

Company Website Country

Date Present Business Started

No. of Employees Principle Business Activity

Type of Business

Corporation - Date of Incorporation

Partnership

General

Sole Proprietorship

State of Incorporation Federal Tax ID # In "Good Standing"?

Management or Owners of the Business:

Social Security #

Title

Ownership

Address

City

State

Zip

Home Phone #:

Cell #

Address

City

State

Zip

Home Phone #:

Cell #

SECTION B CREDIT INFORMATION

REFERENCES - Lisf full Name and Address of Major Suppliers, Banks AND Insurance Agent Information:

1.NAME:

4. NAME:

Phone:

Fax:

Phone:

Fax:

Contact:

Acct:

Contact:

Acct:

2.NAME:

*** INSURANCE AGENT INFORMATION:

Phone:

Fax:

NAME:

Contact:

Acct:

Phone:

Fax:

3.NAME:

Contact:

Policy #:

Phone:

Fax:

State your Liability Coverage :

Contact:

Acct:

1.BANK:

Checking Account #:

Phone:

Fax:

Loan #:

Contact:

Acct:

Loan Balance $

2.BANK:

Checking Account #:

Phone:

Fax:

Loan #:

Contact:

Acct:

Loan Balance $

SECTION C SIGNATURES

By signing below, the undersigned individual, who is either a principal of the credit applicant or a personal guarantor of its obligations, provides written instruction to GPD Capital Services, Inc. or its designee (and any assignee or potential assignee thereof) authorizing review of his/her personal credit profile from a national credit bureau. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for the purpose of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account. A Photostat of facsimile copy of this authorization shall be validd as the original. By signature below, I/we affirm my/our identity as the respective individual/s identified in the above application.

Applicant Signature Date: Applicant Signature Date:

I Agree