Company Information
***This is a sample credit application, feel free to fill it out w/ dummy info & enter your email here to get examples of the autoresponders & notifications automated with this form:
example@example.com
Company Name*
Include your DBA if applicable
State of Incorporation*
Date Incorporated*
Have you been in business for longer than 2 years?*
Yes No
Federal Tax ID Number
Type of Business*
Nature of Your Business*
Is this a medical practice?*
Yes No
Do you have experience in your industry prior to incorporating your business?*
Yes No
Describe your industry experience including employment as a 1099 contractor and other businesses you currently & previously owned or operated:*
What is your specialty?*
Licensed Date*
License Number
Company Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Company Phone*
Area Code Phone Number
Contact Person*
First Name Last Name
Contact Person's Phone*
Area Code Phone Number
Contact Person's E-mail*

Principals, Officers, Partners or Guarantors
Name*
First Name Last Name
Title*
Percent (%) Ownership*
Social Security Number (SSN)*
Home Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
E-mail*
Cell Phone*
Area Code Phone Number
Do you have another principal, officer, partner or guarantor to add?*
Yes No
Name*
First Name Last Name
Title*
Percent (%) Ownership*
Social Security Number (SSN)*
Home Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
E-mail*
Cell Phone*
Area Code Phone Number
Do you have another principal, officer, partner or guarantor to add?
Yes No
Name*
First Name Last Name
Title*
Percent (%) Ownership*
Social Security Number (SSN)*
Home Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
E-mail*
Cell Phone*
Area Code Phone Number
Do you have another principal, officer, partner or guarantor to add?
Yes No
Name*
First Name Last Name
Percent (%) Ownership*
Title*
Social Security Number (SSN)*
Home Address*
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
E-mail*
Cell Phone*
Area Code Phone Number
Do you have another principal, officer, partner or guarantor to add?
Yes No
If you have more than 4 Principals, Officers, Partners or Guarantors, please list each person including all of the following information in the text box below:
- Full Name
- Percent (%) Ownership
- Title
- Social Security Number (SSN)
- Home Address
- Email
- Cell Phone
Use this text box to list every additional Principal, Officer, Partner or Guarantor.

Equipment Information
Equipment Description*
Equipment Cost*
ex: 45000 (no commas or special characters)
Equipment Condition*
New Used
Vendor Company Name*
Vendor Contact Person*
First Name Last Name
Vendor Phone
Area Code Phone Number
Would you like to secure an approval for additional equipment or working capital?*
Yes No
Please Elaborate
Authorization
Declaration/Authorization*
By typing your full name below, recognized as an electronic signature, each of the above-listed Business Owner(s)/Officer(s)/Principal(s) and Business (individually and collectively, “You”) certify that all information and documents submitted in connection with this Funding Application ("Application") are accurate, true, correct and complete; and that You will immediately notify [COMPANY NAME HANDLING CREDIT APP] or any of its representatives, successors, assigns, designees, agents, partners or affiliates (individually and collectively, "Recipients") of any change in such information or financial condition. You further authorize [COMPANY NAME] and/or Recipients to obtain consumer or personal, business and investigative reports, references and other information about You, including, but not limited to credit card processor statements and bank statements, from one or more consumer reporting agencies, such as TransUnion, Experian, and Equifax, and from other credit bureaus, banks, financial institutions, creditors and other third parties, now or in the future. You also authorize [COMPANY NAME] to transmit this Application, along with any of the foregoing information obtained in connection with this Application, to any or all of the Recipients for the foregoing purposes. You agree to adopt this typed electronic representation of your name as your signature and shall be valid as the original. You consent and agree to receive updates from [COMPANY NAME] and/or assignees regarding this account via the telephone or fax numbers or email address provided in connection with this or any future application.
Type Full Name*
Date
Month Day Year
[COMPANY NAME] is committed to protecting your information and respecting your privacy. Information submitted via this form will only be used to evaluate as a credit application. This form and submissions are private and secure.
This is not an approval. A decision with the contract terms and conditions will be based on review of the credit application and subject to underwriting requirements.
Should be Empty:

Company Information

Principals, Officers, Partners or Guarantors

Equipment Information

Authorization