Legal Name of Business:_____________________________________­­­_______

Type (Circle One): Sole P / Partnership / Corp

Business Phone #:_____________________

Fax #:______________________________

Email :_______________________

Address:____________________________

City:_______________________________

State:_____________

Zip:____________

County:_______________

Years in Business:________

Federal ID #:__________________

Corp ID  #:____________________

Authorized Signer & Corresponding Position (Please Print):_______________________________________________________________

Social Security:______________________________________

Home Owner or Renter (Circle One)

Number of Years at Current Address:________________________

Home Address:__________________________________________________________________________________________________

Home Phone #:_______________________

Cell #:______________________________

Pager #:____________________________

Nearest relative not living at the same address:

(required):________________________________

Relation:

_____________________________

Phone Number:

_______________________

Primary Bank Name:____________________________________________________

Account #:_______________________________

Contact Name:__________________________________________

Phone #:_______________________________________________

Non-Credit Card Business Reference:___________________________________________

Account #:__________________________

Contact Name:_____________________________________________________________

Phone #:____________________________

Employer (THIS SECTION IS REQUIRED BY ALL APPLICANTS):__________________________________________

Position:____________________________

Salary:______________________________

Phone #:____________________________

Spouse’s Employer if both will be authorizing purchase: ______________________________________________________________

Position:____________________________

Salary:______________________________

Phone #:____________________________

Payment Preference (Check One):

_______Automatic Withdraw

_______Pay by Check/Billing Statement

IMPORTANT - PLEASE READ BEFORE SIGNING

I understand that Wittern Financial Services is relying on this information in extending credit and I warrant it to be true. I hereby authorize Wittern Financial Services or any bank/and or trade bureau or other investigative agencies employed by Wittern Financial Services to investigate the references herein listed or other data obtained from me or any other person pertaining to my credit and financial responsibility. The undersigned authorizes all parties contacted to release credit information requested, or its successors or assigns.

(signature)

(position of signer)

(date)

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