EZ Credit 2K - F&I Systems

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Application for Retail Store

General Business Information
Registered Business Name*
DBA Name:*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long?
Phone*
Dashes are not needed when entering phone numbers.
Fax number
Dashes are not needed when entering phone numbers.
In business since:*
MM slash DD slash YYYY
Dealer License (Taxpayer ID#)*
Email*
Legal Structure and Ownership
Business Entity*
- Corporation
- Partnership
- Sole Proprietorship
Owners/Principals
Name Title Ownership %
Owner Information
Name*
First Middle Last
Current Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Time at address
Type of home
- Own
- Rent
Mobile Phone*
Dashes are not needed when entering phone numbers.
Social Security Number*
Second Owner Information
Name
First Middle Last
Current Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Time at address
Type of home
- Own
- Rent
Home Phone
Dashes are not needed when entering phone numbers.
Mobile Phone
Dashes are not needed when entering phone numbers.
Social Security Number
Banking and Financing Information
Checking Account
Bank Name*
Address*
Street Address Address Line 2 City State ZIP Code
How long?*
Phone*
Dashes are not needed when entering phone numbers.
Fax
Dashes are not needed when entering phone numbers.
Financing (What finance companies do you currently work with?)*
Company Name Phone How Long?
Additional Information
Has your company ever filed for Bankruptcy protection?*
- Yes
- No
Date of bankruptcy, if applicable.
MM slash DD slash YYYY
Are you aware of any judgments or liens placed against your company?*
- Yes
- No
If yes, please describe
How many locations do you operate?*
Reference 1
Company Name*
Address*
Street Address Address Line 2 City State ZIP Code
How Long?*
Contact Name*
Number*
Reference 2
Company Name*
Address*
Street Address Address Line 2 City State ZIP Code
How Long?*
Contact Name*
Number*
Reference 3
Company Name*
Address*
Street Address Address Line 2 City State ZIP Code
How Long?*
Contact Name*
Number*
Authorization and Certification
The undersigned herby certifies that the foregoing information is true and complete and made for the purpose of determining the undersigned’s eligibility for credit. The undersigned agree that this application shall remain in Great American Finance Company’s property whether or not accepted. The undersigned further authorizes Great American Finance Company to make all inquiries deemed necessary to verify the accuracy of the statements made herein, and to determine the creditworthiness of the undersigned by procuring consumer reports from consumer reporting agencies and credit information from other financial institutions and extenders of credit, references, present and former employers, merchants, landlords, and creditors.
Owner's Name*
First Last
Title*
Signature*
This E-Sign Disclosure and Consent Notice ("Notice") applies to all communications, as defined below, for services provided by EZ Credit 2K, Inc. and our affiliates. Under this Notice, communications you receive in electronic form from us will be considered "in writing”.
Date*
MM slash DD slash YYYY
Owner's Name
First Last
Title
Signature
This E-Sign Disclosure and Consent Notice ("Notice") applies to all communications, as defined below, for services provided by EZ Credit 2K, Inc. and our affiliates. Under this Notice, communications you receive in electronic form from us will be considered "in writing”.
Date
MM slash DD slash YYYY

Name	Title	Ownership %

Company Name	Phone	How Long?

Application for Retail Store

General Business Information

Legal Structure and Ownership

Owner Information

Second Owner Information

Banking and Financing Information

Checking Account

Additional Information

Reference 1

Reference 2

Reference 3

Authorization and Certification

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