** = Required Information
** COMPLETE LEGAL NAME : DATE : (DD/MM/YYYY) ** Email:
SOLE PROPRIETOR
PARTNERSHIP
CORPORATION
LLC
       
** TYPE OF BUSINESS :   FEDERAL ID NUMBER : YEARS IN BUSINESS:
       
       
** MAILING/BUSINESS ADDRESS: COUNTY: ** PHONE NUMBER:
(123-456-7890)		 FAX NUMBER:
(123-456-7890)
EQUIPMENT LOCATION: COUNTY: PHONE NUMBER:
(123-456-7890) 		CONTACT:
 
INSURANCE AGENT:     AGENT'S PHONE NUMBER:
(123-456-7890)
NAME OF LANDLORD OR
MORTGAGE HOLDER: 		  PHONE NUMBER:
(123-456-7890)		      
       
PRINCIPAL / OFFICER / PARTNER * * SOCIAL SECURITY # * * TITLE %OWNED TELEPHONE
** **
         
         
       
BANK / MONEY MARKET ACCOUNTS ACCOUNT # TELEPHONE OFFICER TO CONTACT

BUSINESS

BUSINESS

BUSINESS / PERSONAL

         
TRADE REFERENCES ACCOUNT # TELEPHONE CONTACT
       
EQUIPMENT LEASE REFERENCE ACCOUNT # TELEPHONE CONTACT
       
EQUIPMENT
SUPPLIER: ADDRESS:
         
TYPE OF EQUIPMENT: NEW / USED: COST OF EQUIPMENT:
         
The undersigned individual, recognizing that his or her individual credit history may be a factor in the evaluation of the credit of the applicant, hereby consents to and authorizes the above named business credit provider and any assignee, lender or funding service that may be utilized to obtain and use a consumer credit report on the undersigned, now and from time to time, as may be needed in the credit evaluation and review process, and, if necessary, any collection actions to be taken on the account. The undersigned waives any right or claim they would otherwise have under Fair Credit Report Act in the absence of this continuing consent.

I hereby authorize our banks, trades, and personal credit Bureaus to release credit information to Liberty Financial Group, Inc. and/or its assignees.
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