PLEASE PRINT AND THEN FAX THIS COMPLETED
APPLICATION TO:  (770) 205-0831

4430 Wellington Place
Cumming, Georgia 30040-5246
770-205-6830  •  Toll Free 800-404-6792
 Vendor Name: Anything Automotive
Address: PO Box 364 Gallatin , Mo. 64640
Telephone: 660-334-0202 Fax: 702-537-1599
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Business Legal Name:Line
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All Owners:Line
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Street Address:LineHome Address:Line
City/State/Zip:LineCity/State/Zip:Line
County:LineCounty:Line
Telephone:LineTelephone:Line
Fax Number:LineSocial Security:Line
Contact Officer:LineTitle:LinePercentage of Ownership (%):Line
Person Signing Lease:LineTitle:Line Nature of Business:Line
Proprietorship o    Partnership o    Corporation o    Other o .Line
Years in Business Under Current Ownership:Line
TERMS OF LEASE
Federal Tax I.D. #:LineEquipment Description:Line
Equipment Location:Line Brand and Model:Line
   o Same as Street Address
Total Cost:LineLease Terms:Line
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FINANCIAL REFERENCES IN BUSINESS NAME ONLY
(include banks, leasing companies, equipment or other loans)
Reference #1:LineChecking Acct.#: LineCity/State:Line
Since:Line Phone:Lineo Lease o Loan Acct#:LineContact:Line
Reference #2:LineChecking Acct.#: LineCity/State:Line
Since:Line Phone:Lineo Lease o Loan Acct#:LineContact:Line
Reference #3:LineChecking Acct.#: LineCity/State:Line
Since:Line Phone:Lineo Lease o Loan Acct#:LineContact:Line
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SUPPLIER REFERENCES
  1. Company Name:Line
    City/State:Line
    Telephone:Line
 
  1. Company Name:Line
    City/State:Line
    Telephone:Line
  1. Company Name:Line
    City/State:Line
    Telephone:Line
  1. Landlord Name:Line
    City/State:Line
    Telephone:Line
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I hereby authorize UniSource Capital or its assigns to make a complete credit check on our company and the principals of the same and/or guarantors, as individuals, and to relate this information to others as necessary to secure credit approval. I also authorize the above references to release any information that may be requested by UniSource Capital. A fax or photocopy of this authorization shall be valid as the original. I certify this statement is true and accurate.
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      Signature Title Date