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BUSINESS CREDIT APPLICATION

Phone: (800) 316-1942 / Email: [email protected]

Business Legal Name (and DBA if applicable):*

Business Phone

Business Address

Street Address Address Line 2 City State ZIP Code

If the equipment address is different, please include below:

Legal Business Structure

LLC

Corporation

Sole Proprietorship

Partnership

Years in business under current ownership:

Website

Federal Tax ID

Owners, Officers, Guarantors

Name*

First Last

Home Address*

Street Address Address Line 2 City State ZIP Code

Social Security Number*

Phone*

Email*

Professional Licenses

Percent Ownership*

Please enter a number from 0 to 100.

Additional Owners, Officers, Guarantors

Name*

First Last

Home Address*

Street Address Address Line 2 City State ZIP Code

Social Security Number*

Phone*

Email*

Percent Ownership

Professional License(s)

Are there any additional owners?*

Yes

Additional Owners, Officers, Guarantors

Name*

First Last

Home Address

Street Address Address Line 2 City State ZIP Code

Social Security Number*

Phone*

Email*

Percent Ownership

Professional License(s)

Equipment and Seller Info

Equipment Description

Equipment Cost*

Name of Sales Representative

Terms and Conditions*

I certify this statement and agree to the terms and conditions.

I/We understand that this is an application for business credit ("Application"). By submitting this electronic Application and checking the Acceptance box below, I/We hereby authorize, represent, warrant and agree as follows: (a) Assured Financial, LLC, and their affiliates, employees, assigns, agents, vendor partners, funding referral sources and designees (collectively "Assured") may obtain commercial and consumer credit reports on me/us, investigate references and make other credit inquiries about me/us, and anyone so contacted may release information to Assured; (b) the information in this Application is true, correct and complete, and I/We will immediately notify Assured in writing of any material change in any information; (c) this Application is submitted for financing solely for business or commercial use and not for personal, family or household purposes; (d) I/We am/are a citizen or lawful permanent resident of the United States; (e) this Application will apply to any future request for additional financing and renewals, and all notices, disclosures, authorizations, representations, warranties and agreements shall be deemed repeated for each future request, unless I/We submit a new written application; (f) based upon the contents of the Application, credit information obtained and Assured underwriting criteria, Assured in its sole discretion may elect to either grant or decline to grant credit; (g) I/We agree that this Application is an electronic record using my electronic signature and is binding on me/us; (h) I/We consent and agree to be contacted and receive notices regarding the Application, as well as updates from Assured, its affiliates, and its partners regarding this account via the telephone or fax numbers or email address provided in connection with this or any future Assured application, and if I/We have provided a mobile device number, I/We expressly agree to receive communications at that number from Assured, is affiliates, and its authorized agents; and (i) any and all disputes must be heard in county of Summit, state of Utah.

Equal Credit Opportunity Act Notice

The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law is the Bureau of Consumer Financial Protection, 1700 G Street NW, Washington, D.C. 20006. If your application for credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact Customer Service, Assured Financial, LLC 4383 N Forestdale Dr, Park City, UT 84098, within sixty (60) days from the date you are notified of our decision. We will send you a written statement for reasons of denial within thirty (30) days of receiving a request for the statement.

Phone

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