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Name
of Business:_________________________ Type (Circle
One): Sole P / Partnership / Corp.
Business Phone:(___)__________ Fax:(___)__________ Email Address:_________________
Address:_____________________ City:______________ State:_____
Zip:________________
Country:_____________ Years in Business:___ Federal ID#:_________
Dun&Brad#:________
Owner
Name / Authorized Signer (Please Print):______________________________________
Social Security:_______________
Home
Owner / Renter (Circle One) Number of Years at Current Address:__________________
Home Address:________________________________________________________________
Home Phone:(____)___________ Cell Phone:(____)___________
Pager:(____)____________
Nearest Relative (Required):________________ Relation:________
Phone:(____)__________
Primary
Bank Name:_______________________________ Account #:___________________
Contact Name:____________________________________ Phone:(____)_________________
Noncredit
Card Business Reference:__________________ Account #:___________________
Contact Name:____________________________________ Phone:(____)_________________
Employer
(If Employed Outside of Vending):_________________________________________
Position:____________________________ Salary:____________
Phone:(____)____________
Spouse's Employer:_____________________________________________________________
Position:____________________________ Salary:____________
Phone:(____)____________
Payment
Preference (Check One):__Automatic Withdraw __Pay By Check/Billing
Statement
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IMPORTANT
- PLEASE READ BEFORE SIGNING
I
understand that Wittern Financial Services is relying
on this information in extending credit and I warrant
it to be true. I hereby authorize Wittern Financial
Services or any bank and/or trade bureau or other investigative
agencies employed but Wittern Financial Services to
investigate the references herein listed or other data
obtained from me or any other person pertaining to my
credit and financial responsibility. The undersigned
authorizes all parties contracted to release credit
information requested, or it's successors or assigns.
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_____________________________
(signature) |
_____________________________
(position of signer) |
___________
(date) |
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