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 Partnership General Sole Proprietorship Date of Incorporation
State of Incorporation Federal Tax ID # In "Good Standing"?
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
3. Name
4. Name
***INSURANCE AGENT INFORMATION:
Name
Contact Policy#
State your Liability Coverage
1. Bank
2. Bank
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
