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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 Date of Incorporation

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

 

1. Management or Owners of the Business  Social Security # Birth Date Title Ownership
         

Address City State Zip

Home Phone Cell Phone

 

2. Management or Owners of the Business  Social Security # Birth Date Title Ownership
         

Address City State Zip

Home Phone Cell Phone

 

SECTION B    CREDIT INFORMATION

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

1. Name

Phone Fax

Contact Account

2. Name

Phone Fax

Contact Account

3. Name

Phone Fax

Contact Account

4. Name

Phone Fax

Contact Account

 

***INSURANCE AGENT INFORMATION:

Name

Phone Fax

Contact Policy#

State your Liability Coverage

 

1. Bank

Phone Fax

Contact Account

2. Bank

Phone Fax

Contact Account

Checking Account #

Loan #

Loan Balance $

Checking Account #

Loan #

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 purposes of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account. A Photostat or facsimile copy of this authorization shall be valid 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

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