1455 Lockridge Drive, Suite 100Cumming, GA 30041Phone 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 * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming COUNTY ZIP CODE * BUSINESS STRUCTURE * Select S CorporationC CorporationLLCPartnershipProprietorship CONTACT MOBILE PHONE * START DATE OF BUSINESS * FED. TAX ID NO * EQUIPMENT LOCATION CITY STATE AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP CODE OWNERSHIP LIST ALL OWNERS HAVING 25% OR MORE OWNERSHIP & THEIR PERCENTAGE. PRINCIPAL’S NAME * TITLE * Select C.F.O.Managing MemberMemberC.E.O.Charter PhysicianGeneral ManagerOwnerPartnerPresidentPrincipalPurchasing AgentSecretaryVice President % OWNERSHIP * Generation Select JrSrIIIIIIV HOME PHONE NO * SOC. SEC. NO * HOME ADDRESS (STREET) * CITY * STATE * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP CODE VENDOR CONTACT CONTACT TELEPHONE MANUFACTURER YEAR Select Year 194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 MODEL VIN # MILEAGE OR HOURS ENGINE MAKE AND SIZE TRANSMISSION GAS YESNO DIESEL YESNO ESTIMATED COST OF VEHICLE $ TERM IN MONTHS Select Months 24 Months36 Months48 Months60 Months VENDOR DEPOSIT $ EQUIPMENT VENDOR VENDOR TELEPHONE ADDRESS (STREET) CITY STATE AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP CODE VENDOR CONTACT CONTACT TELEPHONE CONTACT TELEPHONE CONTACT TELEPHONE TYPE OF EQUIPMENT * ESTIMATED COST OF EQUIPMENT * $ TERM IN MONTHS Select Months 24 Months36 Months48 Months60 Months VENDOR DEPOSIT $ Authorization 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 Select C.F.O.Managing MemberMemberC.E.O.Charter PhysicianGeneral ManagerOwnerPartnerPresidentPrincipalPurchasing AgentSecretaryVice President Date Submit