Legal Name of
Business _____________________________________________________________
Mailing Address, City, State, Zip __________________________________ County
_____________
Physical Address, City, State, Zip _________________________________ County
_____________
Phone _______________ Cell ______________ Fax _____________ Email
___________________
Nature of Business ______________________________________ Tax ID#
____________________
Business is a: Corporation ____ Partnership ___ Proprietorship ___ State
Incorporated ______
Date Business Established __/__/__ Estimated. Annual Sales $ ____ Factored
Previously?____
Officers Or
Owner(S)Name |
Social
Security
Number |
%
Owned |
Title |
Home
Address, City, State, Zip |
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FIVE LARGEST CUSTOMERS AND HIGH
CREDIT LIMIT FOR EACH:
| Corporate Name |
Location |
State |
Contact Person |
Limit |
Phone |
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REFERENCES:
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Name |
City, State |
Phone |
Account Number |
Account Officer |
| Bank |
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| Accountant |
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| Attorney |
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THREE LARGEST SUPPLIERS:
| Corporate Name |
Location |
Contact Person |
Phone |
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Answer YES or NO to each of the following questions, if YES,
please provide a detailed explanation.
Do any of your customers buy from you on a "contra" account basis? Or do
you buy anything from your customers?
______________________________________________________________Are your account receivables now assigned, pledged or liened as
collateral for any loans?
__________________________________________________________________________________
Are any taxes past due?
____________________________________________________________
I verify that the above information is accurate and correct:
Signature
_________________________________________________ Date ____________________
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Process Steps
| 1. |
Completion Of Application |
| 2. |
Payment of Due Diligence Fee |
| 3. |
Signed Release of Information |
| 4. |
Credit Search which includes items such
as UCC and tax lien searches |
| 5. |
Assembly of Documentation, which
includes, signed agreement, Notice of Assignment, and a UCC form. |
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WESTBROOK CAPITAL, INC.I understand the information contained in
this statement is provided for the purpose of obtaining or maintaining credit with
Westbrook Capital Inc. on behalf of the undersigned, or persons, firms or corporations in
whose behalf the undersigned may either severely or jointly with others, execute a
guaranty in your favor. Each undersigned understands that Westbrook Capital, Inc. is
relying on information provided herein (including the designation made as to ownership of
property) in deciding to grant or continue credit. Each undersigned represents and
warrants that the information provided is true and complete and that Westbrook
Capital, Inc. may consider this statement as continuing to be true and complete and that
Westbrook Capital Inc. by the undersigned. Westbrook Capital Inc. is authorized to make
all inquires they deem necessary to verify the Westbrook Capital Inc. is
authorized to answer questions about your credit experience with Westbrook Capital Inc.
Date ________. 20____
Signed: ______________________________
Title: ____________________________
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