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SALES INFORMATION
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Name of your salesperson
(if you do not have one, enter "None":
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Amount of credit requested:
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$1-5,000 $5,000-25,000 $25,000+ |
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CUSTOMER INFORMATION
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Current Finance Customer?:
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Current Customer Past Customer New Customer |
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Finance Customer Number:
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Legal Business or Customer Name:
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DBA Name (if any):
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Type of Business:
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Sole Proprietership Partnership Corporation |
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Years in Business:
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Number of Routes:
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Number of Locations:
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Number of Machines:
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Annual Sales:
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Business/Customer Address:
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City:
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State: Zip: |
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Phone:
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Alt/Cell: |
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Fax:
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E-mail: |
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Owner/Authorized Signer 1 Name:
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Social Security Number:
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Owner/Authorized Signer 2 Name:
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Social Security Number:
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CREDIT INFORMATION
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Are you?:
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Homeowner Renter |
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Number of years at address:
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Home Address:
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City:
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State: Zip: |
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Home Phone:
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Nearest relative not living with you:
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Phone:
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Relationship:
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Are you employed outside vending business?
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Yes No |
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If employed outside the vending business, or are in business less than one year,
list the name of employer, your position, salary, years employed and phone number of the business below:
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Trade References (3):
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For purchases over $25,000 we will require the submittal of 1.) last years tax returns and/or current year to date Profit and Loss statement. Please feel free to fax this to our secure fax line at: (716) 822-5300
I understand that Queen City Equipment is relying on this information in extending credit and I warrant it to be true. I hereby authorize Queen City Equipment or any bank and/or trade bureau or other investigative agencies employed by Queen City Equipment to investigate the references herein listed or other data obtained from me or any other person pertaining to my credit and financial responsibility.
BY SUBMITTING THIS APPLICATION I AUTHORIZE ALL PARTIES TO RELEASE CREDIT INFORMATION REQUESTED OR ITS SUCCESSORS OR ASSIGNS.
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