February 7, 2006

GENERAL INFORMATION

Business Name

DBA's/Other Business Names

Primary Address (Headquarters)

City
 State
 Zip
  

Telephone
 Fax
 Date Business Established

Principal Contact (Name & Title)

Email Address
Business Form
 State of Incorporation

Federal Tax ID
Franchise Tax ID
  

Insurance Broker/Agent Name
Address
 Telephone

Attorney Name
Address
 Telephone

Business Bank Name
Address
 Telephone

Number of Accounts
Bank Account Numbers
  

$ Amt. of Receivables Now Open
Approx. # of Accounts
# of Invoices per Month
Standard Credit Terms

Current Lender
Current Contact
 Telephone


OWNERS/OFFICERS/PARTNERS

Name/Title

% Equity

Home Address

City
 State
 Zip




Name/Title

% Equity

Home Address

City
 State
 Zip




Name/Title

% Equity

Home Address

City
 State
 Zip