Rotobrush : Credit Application Form

* Note: All fields are required.

Date (MM-DD-YY):
Sale Rep:
APPLICATION INFORMATION
Business Legal Name (DBA):
Billing Address:
City:

County:

State:

Province (if applicable):
Country:
Zip Code:

Equipment Location: (If other than bill.
Enter N/A if same as billing)

Federal ID:

Nature of Business:

Type of Organization:   Age of Business (Current Ownership):

Contact Name (Full Name)

Title:

Email Address:

Number of Employees:

OWNERSHIP INFORMATION
Owner 1 Name:

Title:

Percentage of Ownership:

DOB (MM-DD-YY):   SSN:   Home Address (include city, state and zip):

Home Phone:

Mobile Phone:

Owner 2 Name:

Title:

Percentage of Ownership:

DOB (MM-DD-YY):

SSN:

Home Address (include city, state and zip):

Home Phone:

Mobile Phone:

BANK & LOAN REFERENCES
Bank Name:

Contact Person:

Phone:

Fax:

Account Number:

Bank Name:

Contact Person:

Phone:

Fax:

Account Number:

TRADE REFERENCES
Name of Supplier:

Contact Person:

Phone:   Fax:   Account Number:   Name of Supplier:

Contact Person:

Phone:   Fax:   Account Number:   EQUIPMENT TO BE LEASED

Description/Package: Equipment Cost (w/shipping):
ACKNOWLEDGEMENT AND AUTHORIZATION

I hereby certify that the information contained in this application is true and correct. I authorize you or your agents to investigate my/our financial responsibility and creditworthiness. I authorize you to update my/our credit profile from time to time in the future as deemed appropriate. I further authorize any of the above references to verify the information above or provide additional information as requested either by phone, facsimile or e-mail. I/we will be held personally accountable for all the monies due to Rotobrush International LLC and/or it's affiliates.

Rotobrush Mobile