Business Credit Application
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Applicant
Business Legal Name *
DBA (if applicable)
Business Street Address *
ZIP*
City
State*
Select State*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Phone # * (123)-123-1234
Applicant's Email *
Website
Legal Structure *
Select Legal Structure *
Corporation
LLC
Sole Proprietor
Partnership
Tax Id * (12-3456789)
State of Inc./Formation *
Select State of Inc./Formation *
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Gross Annual Revenue in Prior Fiscal Year
$
# of Workers
Date Business Started *
Industry Type *
Select Industry Type *
Select
Auto Aftermarket
Beauty Salon, Spa
Bowling Center
Car Wash - Stand Alone
Child Care
Chiropractor
Construction
Dentist, Orthodontist
Education
Equipment Rental / Sales
Fitness
Full-Service Restaurants
Gasoline Stations
General Rental Centers
Grocery and Convenience Stores
Healthcare
Hotel and Motels
Laboratories
Landscape
Manufacturing
Meat Markets
Mining, Quarrying, and Oil and Gas Extraction
Misc Retail
Other Grocery and Related Products Merchants
Physician
Printing
Professional Services
Restaurant - Franchise
Technology Support, Telecomm, Software
Trucking Local Haul
Trucking Long Haul
Veterinary
Equipment & Vendor
| Vendor Code: 138918
Equipment
Finance Amount *
$
Total Project/Equipment Cost
$
Term (in months)
Select Term (in months)
24
36
48
60
72
84
New or Used
Select New or Used
New
Used
Will the above address also be the equipment address?
Yes
No
Vendor Name
Vendor Website
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