H. Brian Lockburner
N25 W23287 Paul Road
Pewaukee, WI 53072
Main (908) 788-9300
Secure Credit Application
Fax: (877) 626-2302
Fax to 877-626-2302
E-mail: brianl@smtfinance.com
General Information:
Complete Legal Name:
Tax ID #:
Street Address:
City:
State:
County:
Zip:
Phone:
Fax:
Cell:
Business Start Date:
Years as Owner:
# of Employees:
Last YE Sales:
Sales YTD:
Backlog:
Email:
Website:
Description of Business (Products, Services, Customers, Concentrations):
Type of Organization - (Check One)
C.Corp
S.Corp
Proprietor
Partnership
LLC
Term - (Check One)
36 Months
48 Months
60 Months
84 Months
Please Answer
Has the company ever declared bankruptcy?
No
Yes
Are there any outstanding lawsuits?
No
Yes
Are there any outstanding tax obligations?
No
Yes
Owner’s (20% or more – if more owners, include information on a separate sheet):
1. Name:
Social Security #:
Street Address:
US Citizen:
Yes
No
City:
State:
Zip:
Date of Birth:
Title:
% Ownership:
2. Name:
Social Security #:
Street Address:
US Citizen:
Yes
No
City:
State:
Zip:
Date of Birth:
Title:
% Ownership:
Bank & Lender Reference:
Bank Name:
Contact:
Phone:
Account #:
Account Type:
Avg. Balance:
1. Lender Name:
Account Type:
Balance:
2. Lender Name:
Account Type:
Balance:
Equipment (Please supply copies of orders for equipment):
Equipment Description:
New
Used
Cost of Equipment:
Supplier Name:
Contact:
Phone:
CUSTOMER CREDIT RELEASE
We hereby authorize SMT Finance LLC
and all assigns there of, to investigate my/our financial responsibility and credit worthiness including the preparation of a credit report. This is my/our authorization for herein bank reference(s) and my/our accountant, attorney or anyone else deemed necessary to release any information requested by telephone or fax as part of SMT Finance LLC normal credit procedures. By submitting this application, you granted consent to and authorize SMT Finance LLC and its agents to obtain commercial and consumer credit reports and make other credit inquiries that it determines necessary, and you represent that each individual listed on this Application as a principal partner, owner, guarantor or obligor likewise has authorized SMT Finance LLC to obtain consumer credit reports and make other credit inquiries that it deem necessary on them. You also warrant the information on or accompanying this Application is true and complete, and you agree to notify SMT Finance LLC of any material change in any such information. You authorize SMT Finance LLC and any credit bureau or investigative agency to investigate the references, statements and other data on or accompanying this Application and you authorize anybody contacted to release credit and financial information requested as part of said investigation. Finally, you confirm that this Application is submitted in connection with financing solely for business and commercial purposes and NOT for personal, family or household purposes.
Important Information.
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
Equal Credit Opportunity Act.
If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact our Customer Service Representative, N25 W23287 Paul Road, Pewaukee, WI 53072 888-559-4032 within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement. 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 applicants 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 concerning this creditor may either be the FDIC Consumer Response Center, 1100 Walnut St. Box #11, Kansas City, MO 64106 or the Office of the Controller of the Currency, Customer Assistance Group, 1301 McKinney Street, Suite 3710, Houston, Texas 77010
Owner Signature:
--------------------------------
(Please print, sign and fax to 877-626-2302)
Date:
Owner:
Date:
Please remember to include a copy of your equipment description
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