CREDIT APPLICATION

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Company Name: Legal Entity (Check appropriate box):
Corporation Partnership Proprietorship
Address:

City: State Zip:
AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Telephone:

Years in Business:
1 2 3 4 5 6 7 8 9 10+
Federal ID#

Name (#1):

Title:

Social Security No.

Home Address:

City: State Zip:
AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
% Ownership:

Home Telephone:

Name (#2):

Title:

Social Security No.

Home Address:

City: State Zip:
AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
% Ownership:

Home Telephone:

Distributor/Equipment Supplier:

Contact Name:

Telephone Number:

Equipment Description:

Equipment Cost:

Name of Bank (Primary):

Account No. (Checking): Account No. (Savings):

Telephone Number:

Bank Contact:

Name of Bank (Secondary-if applicable):

Account No. (Checking): Account No. (Savings):

Telephone Number:

Bank Contact:

Lender/Lessor (#1):

Telephone #:

Account #:

Lender/Lessor (#2):

Telephone #

Account #:

Authorization Check Box : dated: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2003 2004 2005

By checking this box I have contracted to lease equipment from Anthem Capital Group, Inc. As a routine part of Anthem Capital Group Inc. business procedures, bank and trade references are requested. By checking, I authorize the release of credit reports and any information Anthem Capital, and/or it's designee(s) request(s) as part of their normal credit evaluation process. By checking, the applicant warrants that the information stated above is true and accurate.