Company Information:

Legal Company Name:

Address:

City:

State:

Zip:

Authorized Signer/ Title:

Telephone:

Fax:

Nature of Business:

Number of Years in Business:

Personal Information:

Name:

Social Security Number:

Ownership (%)

Homeowner:

Home Address:

City:

State:

Zip:

Home Telephone:

Name:

Social Security Number:

Ownership (%)

Homeowner:

Home Address:

City:

State:

Zip:

Home Telephone:

Bank References:

Name of Bank / Branch

How Long?

Checking account #:

Telephone:

Contact Officer:

Trade References:

Name of Supplier:

City / State:

Telephone:

Contact Person:

Name of Supplier:

City / State:

Telephone:

Contact Person:

 May we email you with
new products and services?

RELEASE AUTHORIZATION:

By E-mailing or Faxing the above form, the undersigned individual as principal of and or guarantor for the Applicant, authorizes Direct Resources, it's designee, assigns or potential assigns, to review his/her credit profile provided by national credit bureaus in considering this Application and for the purpose of the update, renewal or extension of credit to the Applicant or the collection of any resultant accounts. Further, this E-mail or Fax will serve as your authorization to release credit information regarding your accounts to Direct Resources, it's designee, assigns or potential agents.

Applicant Name:

Signature:

Title:

Date:

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