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SECTION A             APPLICATION INFORMATION
Complete Legal Name
Street AddressCityStateZip
Mailing AddressCityStateZip
Phone:  Fax:   Cell # 
E-mail AddressCompany Website     Country  
Date Present Business StartedNo. of Employees   Principle Business Activity 
Type of BusinessCorporation - Date of Incorporation 
Partnership
General
Sole Proprietorship
State of Incorporation  Federal Tax ID #  In "Good Standing"? 
Management or Owners of the Business:Social Security #TitleOwnership
1.
Address CityStateZip 
Home Phone #: Cell # 
2.
Address CityStateZip 
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
   
Copyright © 2006. GPD Capital Services, Inc. All Right Reserved.