.: Business Information :.
Company Name: Contact:
Street Address:
Street Address 2:
City: State: Zip:
Phone: Fax:
Email Address:
Type of Business: Years in Business:
Nature of Business:
Bank Name: Contact:
Bank Account #: Bank Phone:

.: 1st Principal Information :.
Owner Full Name:
Home Address:
City: State: Zip:
Home Phone: Email:
SSN: Ownership Percentage:

.: 2nd Principal Information :.
Owner Full Name:
Home Address:
City: State: Zip:
Home Phone: Email:
SSN: Ownership Percentage:

.: Vendor/Equipment Information :.
Vendor Name:
Vendor Address:
City: State: Zip:
Vendor Phone: Contact:
Equipment Description:
Equipment Cost: $ Term Requested:

ACKNOWLEDGEMENT
I (we) authorize and acknowledge that consumer credit reports and employment history reports about me will be requested by Advanced Capital and third parties in connection with this application and/or on an ongoing basis in connection with updates, renewals, extensions or enforcement of any credit granted as a result of this application. I (we) certify that all of the information in this application is complete and accurate to the best of my (our) knowledge. Third party creditors will rely on this application in deciding whether to grant the credit request. I (we) authorize the sharing of information obtained in connection with this credit request, and any resulting loan, between Advanced Capital and any third party creditor that evaluates the credit request. I (we) agree that this application shall be and remain the property of Performance Capital and any third party creditors that evaluate this credit request, whether or not this application is approved.

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