CREDIT APPLICATION

Company Name: Legal Entity (Check appropriate box):
Corporation LLC 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. (Loan):

Telephone Number:

Bank Contact:

Name of Bank (Secondary-if applicable):

Account No. (Checking):                           Account No. (Loan):

Telephone Number:

Bank Contact:

Lender/Lessor (#2):

Telephone #:

Account #:

Original Lease/Loan Amount:

Commencement Date:

Term:

Monthly Payment:

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 2011 2012 2013

By clicking the “Submit Application” box below, I (we) hereby submit an application request to finance or lease equipment through Anthem Capital Group, Inc. or its designee (“Anthem”). As a routine part of Anthem’s business procedures, bank and trade references are requested along with business and personal credit reports. By clicking the “Submit Application” box below, I (we), as the Owner(s) listed above, authorize Anthem to obtain bank references, trade references, business and personal credit reports, along with any other information Anthem requests as part of Anthem’s credit evaluation process. By clicking the “Submit Application” box below, applicant(s) represent(s) and warrant(s) that the information stated above is true and accurate.