Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Applicant Information *Fax Number *Cell Phone Number *Legal Business Name *Trade Name *Billing Address *City, State, Zip *Email *Years in business Selected Value: 0 Number of Locations Selected Value: 0 Contact Person *Federal ID # *Business Structure * (Corp, LLC, Prop, etc)Personal Information of Officers/Partners/Owners (Include all major owners information)SSNTitleOwnership PercentageHome AddressNumbersNameSSNTitleOwnership %Home Street AddressHome Phone #NameSSN#TitleOwnership %Home Street AddressHome Phone#Vendor InformationPhone Number #Equipment TypeEquipment InformationAddress line 2Terms Requested12mo24mo36mo48mo60moSTATEMENT Customer authorizes POS Credit Corporation ("PCC") or it assigns or potential assigns, financing sources or potential financing sources, to request from, verify and review data or information about the customer, its officers, partners, owners and guarantors including reports from agencies and information from references. PCC is authorized to give credit information about a customer to others. All information provided herein is correct and complete. if business credit is denied customer has the right to a written statement of the specific reasons for the denial to obtain this statement, please contact PCC at address shown below within 60 days of a denial. A fax or photocopy of this authorization shall be valid as the original. PCC 7037 Fly Road East Syracuse, NY 13057Print Name & Title *Signature *Date *Submit
