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Date:________________Years in business:_________________ Firm Name:________________________________________ Billing Address:______________________________________ City:_________________________ State:_______Zip:________ Telephone: (___)______________ Fax (___)_________________ Nature of Business:_____________________________________ OWNERSHIP Check One: Corporation ( ) Partnership ( ) Proprietorship ( ) Date of Incorporation:_____________________ State:_______________ Name of Officers or Owners Address Phone ___________________________________________________ SSN:___________________________ Title:_________________ ___________________________________________________ SSN:___________________________ Title:_________________ ___________________________________________________ SSN:___________________________ Title:_________________ FINANCE Bank:____________________________ Address:_____________________________________________ Telephone:____________________Contact:__________________ REFERENCES Business Name: Address: Telephone: (1)_________________________________________________ ____________________ Contact:__________________________________ (2)_________________________________________________ ____________________ Contact:__________________________________ (3)_________________________________________________ ____________________ Contact:__________________________________ (4)_________________________________________________ ____________________ Contact:__________________________________ Accts. Payable Contact:___________________________ Phone:________________________________ Tax Exempt Status Check One: *Tax Exempt ( ) *Direct Pay Permit ( ) Taxable ( ) *Must provide proof of tax exempt or direct pay status. I (We), the undersigned, hereby certify that the above information is true and accurate to the best of my (our) knowledge. Date:______________ Signed: _________________ Title:________________________ Signed: _________________ Title:________________________ APPLICATION MUST BE SIGNED BY THE OWNER OR PRESIDENT OF THE COMPANY.