Everra Credit Application

Business Information

Legal Business Name

DBA (if applicable)

Business Address

City

State

ZIP

Phone Number

Website (optional)

Type of Business Entity Corporation LLC Partnership Sole Proprietor

Federal Tax ID (EIN)

D-U-N-S Number (optional)

Date Business Established

Annual Revenue ($)

Number of Employees

Principal/Owner Information

Full Name

Title

Home Address

Phone Number

Social Security Number (for credit check)

Stored encrypted, used only for the credit check.

Ownership Percentage (%)

Credit Request

Credit Amount Requested ($)

Purpose of Credit

Preferred Payment Terms Net 30 Net 60 Other

Trade References

Reference 1

Company Name

Phone

Contact Name

Reference 2 (optional)

Company Name

Phone

Contact Name

Reference 3 (optional)

Company Name

Phone

Contact Name

Bank Reference

Bank Name

Account Number

Stored encrypted.

Bank Contact Name

Phone Number

Authorization and Agreement

I hereby authorize Everra to obtain credit and financial information from the references listed above and from credit reporting agencies. I certify that the information provided in this application is true and correct to the best of my knowledge.

Typed Full Legal Name (signature)

I have read and agree to the authorization above.