APPLICATION FORM

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    Business Name (required)
    Date Established
    Street Address *
    City *
    State / Province / Region *
    ZIP / Posta3 Code *
    Phone *
    Federal ID Number *
    Email *
    Fax
    MC Number
    Federal ID Number *
    Type Ownership *
    Currently Under Bankruptcy Protection? *
    Year Filed * (Please enter a number greater than or equal to 1900.)
    Owner One

    * Required

    Owner Two

    * Required

    Accounts Receivable Information
    1. Terms:

      I/we hereby apply for the credit described in this application on behalf of the applicant business. I/we certify that I/we have made no misrepresentation in this application or in any related documents, that all information is true and complete, and that I/we did not omit any important information. I/we agree that any property securing the credit will not be used for any illegal purpose. AltaCapital is authorized to verify with other parties and to make any investigations of my/our credit wither directly or through any agency employed by AltaCapital for that purpose. AltaCapital may disclose to any other interested parties information as to AltaCapital's experiences or transactions with my/our account. I/we understand that AltaCapital will retain this application and any other credit information AltaCapital receives even if no credit is granted. These representations and authorizations extend not only to AltaCapital, but also to any insurer of the credit and to whom AltaCapital may sell all or part of the credit. I/we further authorize AltaCapital to provide to any such insurer or investor any information and documentation that they may request with respect to my/our application or credit.

    * Required