Submitted By

First Name *

Last Name *

Your Email *

Company Information

If you do not have a company yet enter a fictitious name or TBD and use your home address

Company Name *

Doing Business As (DBA)

Street *

City *

State *

Zip Code *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Date Company Formed *

Fed Tax ID

Type of Business

Legal Business Type

Equipment and Vendor Information

Equipment Price *

Equipment Description *

Ownership Information 1 - Required

80% of total ownership must be represented. Please indicate all owners that represent 20% or more in ownership.

Email *

First Name *

Last Name *

Date of Birth *

Title

Ownership % *

SSN *

Ownership Information 2

If there is only one owner leave this section blank.

First Name

Last Name

Date of Birth

Title

Ownership %

SSN

Application Comments

Authorization

By checking the box, each undersigned individual(s), who is either a principal of the credit applicant listed above or a personal guarantor of its obligations, provides written instruction to TCEC or its designee (and any assignee or potential assignee thereof) authorizing review of his or her personal credit profile from a national credit bureau. Such authorization shall extend to obtaining a credit profile in considering the application of the credit applicant and subsequently for the purpose of update, renewal or extension of such credit and for reviewing or collecting the resulting account. Applicant also agrees to allow email or text notifications and updates. A photostatic or facsimile copy of this authorization shall be as valid as the original. Check the box to agree to the terms above.

Signature *

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Validation