*Have Any Principles Ever Had a
Business Failure or Bankruptcy?
Yes No

*Is Your Business Location Owned or Under a Contract Lease?
Owned Leased

*Bank Name:

*Bank Address:

*Account Type:

*Account Number:
*Bank Phone:

Please Read:

This information is submitted for the purpose of obtaining credit. The undersigned authorized you to make
such inquiries as are necessary to obtain credit information and authorizes my bank and/or suppliers to release information regarding my account(s). In consideration for the extension of credit, I/we agree to pay a late charge of 1.5% per month, a true annual rate of 18% per annum on
any amounts past due thirty(30)days
after billing, and to pay all responsible attorney's fees and the cost, if it becomes necessary to file suit to enforce collection.

Is all this Info. True? Yes No

*Type Full Name:

*Your Title:

*Today's Date:
<--Click