|
BUSINESS
INFORMATION
* Required fields.
|
| * Company Name: |
|
* Business Phone: |
|
* Business Fax: |
|
| * Business Address: |
|
* City: |
|
* State: |
|
* Zip Code: |
|
Federal I.D. No: |
|
* Date Started: |
|
* Type of Incorporation/ Ownership:
|
|
* Type of Business: |
|
# of Employees: |
|
Alternate Phone Number: |
|
| OWNER
1
* Required
|
| * Full Legal Name: |
First:
M.I.
Last:
|
* Title: |
|
* Ownership %: |
|
* SSN Number: |
|
Home Phone: |
|
Cell Phone Number: |
|
Alternate Phone Number: |
|
* Email Address: |
|
* Home Address: |
|
* City: |
|
* State: |
|
* Zip Code: |
|
| OWNER
2
|
Full Legal Name: |
First:
M.I.
Last:
|
Title: |
|
Ownership %: |
|
SSN Number: |
|
Home Phone: |
|
Cell Phone: |
|
Alternate Phone Number: |
|
Email Address: |
|
Home Address: |
|
City: |
|
State: |
|
Zip Code: |
|
|
|
Please
Describe what your Financial needs are:
|
| Please be specific.
(e.g. If applying for equipment financing, include
the Year, make, model, miles, hours, etc.)
|
* Terms of Financing: |
|
* Purchase Price: |
|
| Down Payment Amount? |
|
Vendor(s) Name(s): |
|
Phone: |
|
Contact: |
|
* Has Any Owner/Officer filed Bankruptcy
in the last 5 Years?
|
Yes
No
|
|
BANKING
INFORMATION
|
Name of Bank: |
|
Contact: |
|
Bank Phone Number: |
|
Address: |
|
City: |
|
State: |
|
ZIP Code: |
|
First Account Number
(savings, checking, other): |
|
Second Account Number
(savings, checking, other): |
|
|
By checking this box, the Applicants represent
and warrant that all credit and financial information
submitted is true and correct and that Miriah Financial Group and its assigned, may obtain any credit
information necessary pertaining to this application.
Submitting
this application is equivalent to a signature. |
|
|
