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Vending Machine Finance Application

Seller Information
Enterprise Vending (402) 895-9685
Omaha NE
*Amount of Credit Requested:  $0-$5,000   $5,000-$25,000   $25,000+
Business Information
*Current Finance Customer:  Current Customer   Past Customer   New Customer
Finance Customer Number: 
*Type of Business:  Individual    Proprietorship    Corporation    Other
*Years in Vending:  Not in Vending    New Vendor    1-2 years    3-4 years    5+ years
Number of Routes:     Number of Locations: 
Number of Machines:     Annual Vending Sales: 
Customer Name (Legal): 
*First Name: 
*Middle Initial: 
*Last Name: 
*Business or DBA Name:  *If none, enter "None".
*Business Address Line 1: 
Business Address Line 2: 
*Business Phone:   -   - 
*Cell Phone/Alternate:   -   - 
Business Fax:   -   - 
Owner/Authorized Signer 1: 
*First Name:    
*Last Name: 
*Social Security Number:   -   - 
Owner/Authorized Signer 2: 
First Name:    
Last Name: 
Social Security Number:   -   - 
Credit Information
Number of Years at Address: 
   Home Owner    Renter
Same as business address: 
Yes    No
Address Line 1: 
Address Line 2: 
Phone:   -   - 
Nearest Relative not living with Customer: 
First Name: 
Last Name: 
Phone:   -   - 

Employment Information
*Employed Outside of Vending?    Yes    No
Employer 1
       Employer:     Salary: 
       Position:     Years Employed: 
       Phone:   -   - 
Employer 2
       Employer:     Salary: 
       Position:     Years Employed: 
       Phone:   -   - 
Trade References
Company Name:     Phone:   -   - 
Company Name:     Phone:   -   - 
Company Name:     Phone:   -   - 
Important Notice
For purchases over $25,000 we will require the submittal of, 1) last years tax returns and/or 2) current year to date Profit & Loss statement.  Please feel free to fax this information to our secure fax line (702) 977-6591.
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.
Please indicate your consent to the above terms by clicking on the "I Agree" button below. By providing your consent, you also confirm that you are able to access all of the disclosures, records, and other information provided to you in electronic form.  If you have any questions about this notice, please contact the Finance Company at (800) 898-7533.
I Agree
*Email Address: 
*Confirm Email Address: 
Upon submitting form, you will be directed back to the on-line vending machine catalog.