Credit Application

In order to assist Bridge Business Credit in the continuing evaluation of the financing being considered on our behalf and to expedite the preparation of any documentation which may be required, we hereby submit and represent the following information about our company, its organizational structure and other matters of interest to Bridge Business Credit:

"*" indicates required fields

1Business Information

2Shareholders and Officers

3Taxes, Lawsuits and Lien Information

4General

Legal name of company*

Other d/b/a's or trade names

Executive Office

Address Line*

City*

State*

ZIP Code*

Phone*

Fax

County*

Website

Business formed as:

Corporation

S Corp

LLC

For others, please specify

Date of incorporation*

MM slash DD slash YYYY

State of incorporation*

Provide Incorporation documents, Articles, By-Laws and/or business filings

Drop files here or

Max. file size: 1 GB.

Is the company currently in good standing under the laws of applicable states in which you conduct business?

Is the company currently in good standing under the laws of applicable states in which you conduct business?*

Yes

Please Explain

The company is affiliated with, or has ownership in the following companies (including subsidiaries and partnerships):

Affiliated Company

Company Name	Address	Type of Operation	Relationship	Actions

There are no Companies.

Maximum number of companies reached.

Names and business locations utilized by the corporation during the past 5 years:

Business Name	Address Line	City	State	ZIP Code	Actions

There are no Businesses Utilized by the Corporation.

Maximum number of businesses utilized by the corporation reached.

Has the company ever operated in any other state under any other name?

Has the company ever operated in any other state under any other name?*

Yes

Please Explain*

Total Authorized # of Shares:

Title/Position	First Name	Last Name	Home Address	SSN	Phone	Date of Birth	Email	WITH SIGNATORY POWERS	WITH AUTHORITY TO SIGN FOR AND REQUEST ADVANCES	Actions

There are no Shareholders and Officers.

Maximum number of shareholders and officers reached.

Members of the Board of Directors of the Corporation

Chairman

First Name*

Last Name*

Members

First Name	Last Name	Actions

There are no Entries.

Maximum number of entries reached.

With respect to the Shareholders/officers noted above, such principals are affiliated with or have ownership interest in the following entities, excluding the subject corporation above.

Company Name	Address	Ownership %	Relationship	Actions

There are no Company.

Maximum number of company reached.

Federal Tax ID # for the corporation*

Are taxes current?

Yes

If no, please explain*

Total unpaid balance (including penalties and interest)

Is there a payment plan in place?

Is there a payment plan in place?*

Yes

If yes, please explain*

Please Include a copy of the Payment Agreement with this application:

Please Include a copy of the Payment Agreement with this application:*

Drop files here or

Max. file size: 1 GB.

Are there any tax liens filed against the company, its subsidiaries and/or affiliates, or any of its shareholders/officers?

Corporate tax returns have been filed through year-end

Payroll tax returns and deposits have been filed through

Does the corporation utilize a payroll service?

Yes

If yes, please list names of payroll service

Are there any other delinquent taxes due other than those noted above?

Yes

If yes, please explain (optional)

Has the corporation ever filed for bankruptcy or currently under a bankruptcy proceeding?

Yes

If yes, please explain*

Are there any lawsuits, judgements of litigation pending againts the company, its subsidiaries and/or affiliates, or any of its shareholder/offciers

Yes

If yes, please explain*

Is the corporation in violation of any laws ro regulations of OSHA, EPA, or any other Federal Government agency or of any rules, requirements or ordinances of any state or local jurisdiction in which it transacts business?

Yes

If yes, please explain*

Counsel for the corporation*

Address Line*

City*

State*

ZIP Code*

Phone*

Fax

Email*

CPA for the Corporation*

Address line*

City*

State*

ZIP Code*

Phone*

FAX

Email*

The applicant signing below certifies that all information provided above is true and accurate, and if subsequent material changes occur. Great Lakes Business Credit will be notified, in writing, of said changes. Until such notification, Great Lakes Business credit shall be entitled to rely on the forgoing in all respects. Great Lakes Business Credit, and/or its agents, is authorized to access all credit information available on the corporation, its subsidiaries, affiliates, and/or other business with common ownership. This may include credit reporting services, trade, bank and personal credit reference, accounts receivable confirmations and verification and any other information that may be available. Applicant also authorizes Great Lakes Business Credit to file an initial financing statement covering all assets of the applicant in the jurisdiction of its organization.

Signature

Agreed*

Title*

Date*

MM slash DD slash YYYY

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Executive Office

Members of the Board of Directors of the Corporation

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