Company Name: ______________________________
Contact Name & Title: __________________________
Address: _____________________________________
City, State Zip: ________________________________
Federal Tax ID: _______________________________
Business Phone: ______________________________
Cell Phone: __________________________________
Fax: ________________________________________
Email: _______________________________________
Year Started: _________________________________
Year Started Current Ownership: _________________
Business Type: Partnership LLC SoleProp
S-Corp Corporation Non Profit
Principal I Name: _______________________________
Phone #: ___________________ % Ownership: ______
Social Security #: _____________ Birthdate: _________
Principal II Name: ______________________________
Phone #: ___________________ % Ownership: _____
Social Security #: _____________ Birthdate: _________
Bank Reference
Bank Name: _________________________________
Account #: __________________________________
Contact: ____________________________________
Phone: _____________________________________
Trade Reference
Trade Name: ________________________________
Account #: __________________________________
Contact: ____________________________________
Phone: ____________________________________________
Vendor: Custom Northeast Repair Services
Vendor Phone: (603) 548-0255
Equipment Type: _______________________________
New Used
Estimated Equipment Cost: _______________________
Time Frame for Purchase: ________________________
Monthly Budget for Purchase: _____________________
Signature: X___________________________________
Print Name: ____________________________________
Title: __________________________________________
Date: __________________________________________
Delivery of this application bearing a fascimile signature(s) shall have the same force and
effect as if the application bore an inked original signature(s). The applicant certifies that
all information provided is true, correct and complete and that the account will be used
soley for business and commercial purposes. The applicant, owner(s) and guarantor (if
any) authorize Direct Capital Corporation or its designee(s) or assignee(s) to obtain any
information it may request from any business or consumer reporting agency(ies) or other
sources that provide credit reports, account history information, credit and employment
history or similar information; such authorization shall extend to update renewal or credit
and for reviewing or collecting the account. The applicant acknowledges that, based upon
such information and other factors which may apply, Direct Capital or its assignee(s) or
designee(s), in their sole discretion, may either grant or decline to grant credit. By signing
above, I also wish to continue to receive updates from Direct Capital Corp. regarding our
account. Information should be sent to the fax and/or email address given for the
account.
