Online Application – United Funding

1455 Lockridge Drive, Suite 100
Cumming, GA 30041

Phone 770-844-8444 Fax 770-844-0242

credit app

B U S I N E S S Please enter the correct legal name of your company. If you are a Sole Proprietor it should read, "John Doe dba XYZ Company". DO NOT USE A PO BOX.

BUSINESS NAME*

DBA

CONTACT EMAIL

TELEPHONE

ADDRESS (STREET)

CITY

STATE

COUNTY

ZIP CODE

BUSINESS STRUCTURE

CONTACT MOBILE PHONE

START DATE OF BUSINESS

FED. TAX ID NO

EQUIPMENT LOCATION

CITY

STATE

ZIP CODE

OWNERSHIP LIST ALL OWNERS HAVING 25% OR MORE OWNERSHIP & THEIR PERCENTAGE.

PRINCIPAL’S NAME

TITLE

% OWNERSHIP

Generation

HOME PHONE NO

SOC. SEC. NO

HOME ADDRESS (STREET)

CITY

STATE

ZIP CODE

MOBILE PHONE NO*

Add Ownership Remove

BANKS

BANK

BRANCH

FAX

TELEPHONE

ACCOUNT UNDER NAME OF

CHECKING ACCT. NO

CONTACT OFFICER

Add Bank Remove

TITLED COMPLETE THIS SECTION FOR TITLED VEHICLES ONLY

VENDOR NAME

VENDOR TELEPHONE

ADDRESS

CITY

STATE

ZIP CODE

VENDOR CONTACT

CONTACT TELEPHONE

MANUFACTURER

YEAR

MODEL

VIN #

MILEAGE OR HOURS

ENGINE MAKE AND SIZE

TRANSMISSION

GAS

DIESEL

ESTIMATED COST OF VEHICLE

TERM IN MONTHS

VENDOR DEPOSIT

EQUIPMENT

VENDOR

VENDOR TELEPHONE

ADDRESS (STREET)

CITY

STATE

ZIP CODE

VENDOR CONTACT

CONTACT TELEPHONE

TYPE OF EQUIPMENT

ESTIMATED COST OF EQUIPMENT

TERM IN MONTHS

VENDOR DEPOSIT

Authorization

By checking this box, Applicant represents and warrants that all credit and financial information submitted to United Funding is true and correct. You also agree that United Funding or their assigns may obtain information necessary pertaining to this application including, but not limited to owners, officers or guarantors. Applicant agrees to furnish financial statements upon request. Applicant authorizes United Funding or their assigns to investigate the references, statements or other data herein listed.

Signature

Clear

TITLE

Date

If you are human, leave this field blank.