Who We Serve

Legal Structure of Business

Sole Proprietorship

General Partnership

Corporation

Other

Business Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Phone Number *

(###)

###

####

Do you Rent or Own?

Rent

Own

Name *

First Name

Last Name

Phone

(###)

###

####

Personal Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

AUTHORIZATION AND CONSENT OF PERSONAL INFORMATION

By clicking "YES", I/We the applicant and/or guarantor confirm the information given in this application is true/complete and you authorize us to rely on and use this information in order to confirm your identity and evaluate your credit worthiness, in relation to the receipts purchase agreement being entered into. You also agree that we, our affiliates and any third parties acting for us or on our behalf (hereinafter collectively "us", "we", or "our"), may obtain a credit report or other credit information from any credit reporting agency, credit bureau or credit grantor, and may hold, use, exchange, and disclose your personal information, as required, in order to administer your contract, secure the assets being financed, or as required or permitted by law. You also authorize us to use your personal information for internal statistical analysis purposes and for contacting you regarding future receipts purchase offers.

YES

NO