BLANK FAX

Please fax this application to: 818.597.2604

COMPANY INFORMATION

Age

Company Name:

Contact:

Address:

Phone:

City, State, Zip:

Fax:

Business Description: Website:

Fed. Tax I.D. #:

Type of Business: □ Proprietor □ Partnership □ Corp □ LLC

Date Est./State of Organization:

OWNERSHIP INFORMATION

Name:

Title:

Home Address:

SSN:

City, State, Zip:

% Owned:

Phone:

Time Owned:

Name:

Title:

Home Address:

SSN:

City, State, Zip:

%Owned:

Phone:

Time Owned:

BANK/LENDER REFERENCES

Name of Bank/Branch:

Account #:

Contact:

Phone:

Date Opened:

Type: □ Checking □ Savings □ Lease □ Loan

Name of Bank/Branch:

Account #:

Contact:

Phone:

Date Opened:

Type: □ Checking □ Savings □ Lease □ Loan

EQUIPMENT INFORMATION

Vendor: POSnet

Contact Name:

Phone:818-597-2627

Cost: $

Equipment Description:

DECLARATION

By my/our signature on this Application, either as a principal of the applicant or a personal guarantor of applicant’s obligations, I/we hereby certify that all information contained in this Application and all attachments hereto, are true and complete to the best of my/our knowledge, and are made for the purpose of obtaining credit. I/we authorize POSnet, or its designee (and any assignee or potential assignee thereof), to verify any of the information from whatever source it deems appropriate, which authorization shall extend to obtaining and review of my/our personal credit profile from a national credit bureau in considering this Application and subsequently for the purpose of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account. If this Application for business credit is denied, you have the right to a written statement of the specific reasons for denial. To obtain the statement, contact POSnet, or its designee within 60 days from the date you are notified of our decision. We will send you a written statement of the reasons for the denial within 30 days of receiving your request for the statement. NOTICE: The Federal Equal Opportunity Act prohibits creditors from discriminating against applicants on the basis of race, color, religion, national origin, sex, marital status, or age (provided the applicant has the capacity to enter into a binding contract); or because all or a part of the applicant’s income derives from any public assistance program or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, D.C. 20580. A Copy or Facsimile of this Agreement with Signature shall be Considered to be an Original.

Applicant:___________________________________________Signature:X______________________________________Date:_____________________