Company Information Full Business Name Legal Name (if different): Country Select CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo The Democratic Republic Of TheCook IslandsCosta RicaCote D'Ivoire (Ivory Coast)Croatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFiji IslandsFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambia TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernsey and AlderneyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong S.A.R.HungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau S.A.R.MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMan (Isle of)Marshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlands AntillesNetherlands TheNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory OccupiedPanamaPapua new GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent And The GrenadinesSaint-BarthelemySaint-Martin (French part)SamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth SudanSpainSri LankaSudanSurinameSvalbard And Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabwe *State/Province Select State City Select City Street Postal Code / Zip Business Address Business Phone: Fax: Email: Business Website Structure C CorporationS CorporationD/B/APartnershipSole ProprietorshipLLC Years in Business Do you have any other business addresses? yesno If Doing Business At places Other Than Principal Place Of Business/Corporate Office, List All Additional Addresses: Has there been a change of business name or ownership within the last five years? yesno If yes, please describe: Describe the primary source(s) of business activity: Tax Information Federal Tax ID#: Are any Federal or State tax returns under audit? yesno Do you have any Federal or State taxes overdue? yesno If yes, have any liens been filed? If yes, explain Principal / Corporate Officer Information Enter information pertaining to all Business Owners or Corporate Officers: 1. Title Name Home Phone Home Address Social Security #: Date of Birth Drivers Lic. State and #: Has been convicted of a felony? yesno If yes, explain 2. Title Name Home Phone Home Address Social Security #: Date of Birth Drivers Lic. State and #: Company Banking Information Bank Name Contact Phone Address Checking Account # Savings Account # Financial History Attach any relevant explanatory information relating to answers to the following questions. Has Business ever declared bankruptcy? yesno Is Business or its principal's Defendant(s) in any legal actions? yesno Are any Liens currently placed against Applicant’s Accounts Receivable (or are your Accounts Receivable pledged as collateral)? yesno Does Business have any outstanding business loans? yesno If yes, please provide the Name of the Financial Institution: Phone Address Loan Amount Collateral pledged Has name previously factored? yesno If yes, name of the previous factor Attachment Checklist To complete the application, Americus Credit must conduct due diligence and verify the applicant’s legal standing and personal identity with associated business owners and/or corporate officers. Please include the following documents to ensure a speedy response: Two years company financial statements, if statements are not audited or reviewed provide Last two years corporate tax returns including all schedulesCurrent company Interim financial statement (Not older than 90 days)Personal Financial Statement (Not older than 90 days)Last two years personal tax returns (including all schedules)Current Accounts Receivable aging report Current Accounts Payable aging reportCopy of Licenses (MJB only)Business planCompany debt scheduleAny relevant press releases, press coverage, or product literature that might help Americus Credit familiarize itself with products and/or services offered by your company.Invoice(s) of equipment that you’re purchasing Credit Authorization I authorize I hereby certify that the information contained in this credit application is true and accurate and I hereby authorize ACG, its partners, and lenders to obtain consumer credit reports relating to individual credit history and/or creditworthiness and any other information regarding Commercial Applicant and its owners and principals from third parties to verify any information provided on the Application. I hereby authorize the filing and recording of UCC financing statements showing the Lender’s interest in all the business assets and grant ACG the right to execute them in our company name or by the representative. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for update, renewal, or extension of such credit or additional credit and for reviewing or collecting the resulting account. I/we affirm my/our identity as the respective individual(s) identified in this application.