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APPLICANT / BUSINESS ENTITY
Business Type*
- Corporation
- Limited Liability Co.
- General Partnership
- Limited Partnership
- Sole Proprietorship
Name Of Business*
Owner's name as shown on drivers' license
Owner's name as known by creditors
Business name as used on invoices
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone
FAX
Other
Contact Email
Business established Date*
MM slash DD slash YYYY
State*
Charter or Registration No*
Federal ID No
Charter No.
Any trade or assumed business names (registered or not)?
- Yes
- No
If Yes, list names and where registered
Prior business names used within the last 5 years
How did you hear about Pendleton Capital?

VENDOR REFERENCES
List primary 3 Vendors
A) Industry
Vendor Name
Contact
Phone
Balance
Credit Limit
B) Industry
Vendor Name
Contact
Phone
Balance
Credit Limit
C) Industry
Vendor Name
Contact
Phone
Balance
Credit Limit
ACCOUNTS RECEIVABLE INFORMATION
A/R Bal
1-30 days
31-60 days
over 90 days
Amount invoiced last 30 days
Last 12 months
Number of Active customer accounts (AVG)
Invoice size
Normal Terms of Sale
Has Applicant ever financed or sold its accts receivable?
- Yes
- No
If Yes, name financer
Do any of Applicant's accts receivable presently serve as collateral for any purpose?
- Yes
- No
If Yes, explain
Is Applicant or any Owner related to any customer account, in whole or in part? (ownership, parent, subsidiary, partner, affiliate)
- Yes
- No
If Yes, list names
Name Customer Accounts who have, or potentially will, extend credit to Applicant (such as, Customers who are also Vendors)

CUSTOMERS
List top 5 Customers in order of monthly billing amount
1) Customer
Address
Contact
Telephone
Avg. Sales/mo
2) Customer
Address
Contact
Telephone
Avg. Sales/mo
3) Customer
Address
Contact
Telephone
Avg. Sales/mo
4) Customer
Address
Contact
Telephone
Avg. Sales/mo
5) Customer
Address
Contact
Telephone
Avg. Sales/mo
DECLARATION STATEMENT / AUTHORIZATION
Be it known that all information provided in connection with this form is for the purpose of aiding Pendleton Capital Group, Inc. (PCG) in its consideration of entering into a contractual relationship with the Applicant. The above responses are true and accurate to the best of my knowledge and belief, and PCG may rely upon the same for all of its purposes. Furthermore, any party referenced in this form may rely upon this statement as authorization from Applicant to freely respond to any inquiries made by PCG regarding Applicant.
Applicant's Name
By
Name
Title
Date
MM slash DD slash YYYY

APPLICANT / BUSINESS ENTITY