Store Design & Fixture Leasing: Signup

EQUIPMENT FINANCING CENTER

All information is required.

Company Information

Company Name:	Company Address:

City:	State:	Zip:	Telephone:

Referring Vendor Name:	DBA:

Fax:	Years in Business:	Federal Tax ID:	Type of Business:

Personal Information

First Name:	Last Name:	Title:	Social Security Number:

Home Address:	City:	State:	Zip:

Home Phone:	Alternate Phone:	Email Address:	100% Owner:
			Yes No

Business Information

Bank Name:	Account Number:	Bank Phone:

Bank Address:

DECLARATION
I hereby certify (i) the information above is true and correct, (ii) you are hereby authorized to investigate all bank, credit and trade references, and said references are hereby authorized to release any requested information to you or your nominee, (iii) such authorization shall extend to obtaining personal credit profile in considering this application and subsequently for the purposes of update, renewal or extension of such credit or additional credit for reviewing or collecting the resulting the account, (iv) this information may be transmitted by us to you and by you to underwriter(s) for the purpose of granting one credit, either electronically or manually, and that by submitting this application, I take full responsibility for transmission thereof, (v) I am over 18 years of age, (vi) I acknowledge my rights under the Fair Credit Reporting Act, (vii) I consent to receive facsimiles and emails sent Five Point Capital and its affiliates for the purposes of transmitting account updates, requests for information and notices, and (viii) this request is for business and not for consumer purposes.

YES I AGREE THAT THE INFORMATION I AM SUBMITTING IS TRUE AND CORRECT AND AGREE WITH THE TERMS IN THE ABOVE DECLARATION.

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