EFF - Template - Credit Application

Company Information
Company Name*
Include your DBA if applicable
State of Incorporation*
Date Incorporated*
Have you been in business longer than 2 years?*

YesNo
Federal Tax ID Number
Type of Business*
Nature of Your Business*
Is this a medical practice? *

YesNo
What is your specialty?*
Licensed Date*
License Number
Do you have experience in your industry prior to incorporating your business?*

YesNo
Describe your industry experience including employment as a 1099 contractor and other businesses you currently & previously owned or operated:*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Phone*
Contact Person*

First NameLast Name
Contact Person's Phone*
Contact Person's E-mail*
example@example.com

Principals, Officers, Partners or Guarantors
Name*

First NameLast Name
Title*
Percent (%) Ownership*
Social Security Number (SSN)*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Cell Phone*
Do you have another principal, officer, partner or guarantor to add?*

YesNo
Name*

First NameLast Name
Title*
Percent (%) Ownership*
Social Security Number (SSN)*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Cell Phone*
Do you have another principal, officer, partner or guarantor to add?

YesNo
Name*

First NameLast Name
Title*
Percent (%) Ownership*
Social Security Number (SSN)*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Cell Phone*
Do you have another principal, officer, partner or guarantor to add?

YesNo
Name*

First NameLast Name
Percent (%) Ownership*
Title*
Social Security Number (SSN)*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Cell Phone*
Do you have another principal, officer, partner or guarantor to add?

YesNo
If you have more than 4 Principals, Officers, Partners or Guarantors, please list each person including all of the following information in the text box below:
- Full Name
- Percent (%) Ownership
- Title
- Social Security Number (SSN)
- Home Address
- Email
- Cell Phone
Use this text box to list every additional Principal, Officer, Partner or Guarantor.
Since you've provided less than 100% of the ownership, please include information that we may need in evaluating your application:

Equipment Information
Equipment Description*
Equipment Cost*
ex: 45000 (no commas or special characters)
Equipment Condition*

NewUsed
Vendor Company Name*
Vendor Contact Person*

First NameLast Name
Vendor Phone
Would you like to secure an approval for additional equipment or working capital?*

YesNo
Please Elaborate
Authorization
Declaration/Authorization*

By typing your full name below, recognized as an electronic signature, each of the above-listed Business Owner(s)/Officer(s)/Principal(s) and Business (individually and collectively, “You”) certify that all information and documents submitted in connection with this Funding Application ("Application") are accurate, true, correct and complete; and that You will immediately notify Acxion Financial (“Acxion”) or any of its representatives, successors, assigns, designees, agents, partners or affiliates (individually and collectively, "Recipients") of any change in such information or financial condition. You further authorize Acxion and/or Recipients to obtain consumer or personal, business and investigative reports, references and other information about You, including, but not limited to credit card processor statements and bank statements, from one or more consumer reporting agencies, such as TransUnion, Experian, and Equifax, and from other credit bureaus, banks, financial institutions, creditors and other third parties, now or in the future. You also authorize Acxion to transmit this Application, along with any of the foregoing information obtained in connection with this Application, to any or all of the Recipients for the foregoing purposes. You agree to adopt this typed electronic representation of your name as your signature and shall be valid as the original. You consent and agree to receive updates from Acxion and/or assignees regarding this account via the telephone or fax numbers or email address provided in connection with this or any future application.
Type Full Name*
Date

MonthDayYear
Acxion Financial is committed to protecting your information and respecting your privacy. Information submitted via this form will only be used to evaluate as a credit application. This form and submissions are private and secure.

This is not an approval. A decision with the contract terms and conditions will be based on a review of the credit application and subject to underwriting requirements.
Type
Should be Empty:

Company Information

Principals, Officers, Partners or Guarantors

Equipment Information

Authorization