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Business Name:  _____________________________________________________

Type of Business:    Limited Partnership _____    Sole Proprietorship _________

                                            General Partnership _____    Corporation _______________

Federal ID# or Social Security #:  ____________________________

Address and Phone:  _____________________________________________________ ______________________________________________________________________


Owner/President: _______________________________________________________ Address and Phone: _____________________________________________________ _____________________________________________________________________


Date Business Started: _____________________


Amount of Credit Requested: ________________

Bank: ____________________ Account #: ________________________


Credit References:                                                                            Trade References:

____________________________                                           _____________________________ ____________________________                                                                                                            _____________________________ ____________________________                                                                                                            _____________________________

____________________________                                           _____________________________

____________________________                                           _____________________________


Have you ever been a defendant in a lawsuit?

Yes ____  No ____

If yes, list and describe the lawsuits: ______________________________________________________________________


The undersigned consents to the release of credit history.  We recognize that if credit is extended, it may be canceled without notice.



____________________________                                           _____________________________

Borrower                                                                                            Date



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