Customer Information Form
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Legal Business Name: ________________________________________________________________________
(
Please enter exact name as registered with the State including any d/b/a)
Business
Address: __________________________________________ _________________________________________
__________________________________, _______________, ___________
Equipment
Location(s): _______________________________________________________________________________
If necessary, please continue on separate page
Structure:
Federal ID: ____--______________
Corporation
Subchapter S
LLC
Partnership
LLP
Proprietorship
State of Formation: _____________________
Date Entity Formed: ___________________
Month/Year
Contact: _______________________________
E-mail: ____________________________________________
(Name)
Please check which number is best to reach you:
Office: __________________________
_______
Extension
Mobile: ________________________________________
Fax: __________________________________
Other:
________________________________________
Approximate Amount of Financing needed:
Number of Stores owned:
$ _____________________
_____________
Owner: _____________ _______________________________
_____________________
____________
Name/Title
(Signature required below)
Social Security #
% Ownership
Owner: _____________________________________________
_____________________
____________
Name/Title
(Signature required below)
Social Security #
% Ownership
If more than 2 owners, please list on separate page.
Bank Reference: _________________________________________
______________________________
Bank Name
Account Number
_______________________________
_____________________________
________________________
Individual to Contact
Phone Number
Fax Number
Customer authorizes Par Finance Corporation ("PFC") or its assigns to request, verify and review data or information about the customer, its
officers, partners, owners and guarantors including reports from agencies and information from references. All information provided herein is
correct and complete. If business credit is denied, customer has the right to a written statement of the reasons for the denial. To obtain a
statement, please contact PFC at address shown below within 60 days of a denial.
By:
Signature
Please print name
Date
By:
Signature
Please print name
Date
Questions? Please contact Dick Kidney or Eric Will
e-mail:
phone:
fax:
800-875-0138 ext. 122
800-869-0071
e-mail:
phone:
fax:
800-875-0138 ext. 230
800-869-0071
PAR Finance Corporation ● M&T Bank Building ● 101 South Salina Street, Suite 1020 ● Syracuse, NY 13202
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Parent category: Business