BUSINESS INFORMATION
Full Legal Name Tax ID #

Business Address

Street Address: City: County: State: Zip Code:

Phone Number: Fax: Cell:
Yrs in Business:
Email: Other contact info: Website:
Number of employees : Years in Business: Last Years Gross Revenues:
Business Type: Sole Proprietorship   Partnership   LLC   Corporation
PRINCIPAL INFORMATION
Name:  Ownership:  Title:

Home (Street) Address:  City:  County: State: Zip Code:

Home Phone :   Email:   Cell Phone:    Social Security #:
Gross Annual Icome: Homeowner  Rent   Other
Monthly Housing Payment:   Mortgage Balance:  Estimated Value:
Mortgage Holder
Bank InfoRmation
Bank : Checking Saving  Current Balance:
Bank : Checking Saving  Current Balance:
Business Debt
Instituition
Type Of Debt
Orginal Amount
Present Balance
Interest Rate
Maturity Date
Monthly Payment
Collateral

By signing below, the undersigned individual, who is either a principal of the credit application or a personal guarantor of its obligations, provides written instruction to deftco.corp, its affiliates or its designee (and any assignee or potential 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 purposes of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account. A photostat or facsimile copy of this authorization shall be valid as the original. By signature below, I affirm your identity as the respective individuals identified in the above application.

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