Apply Now "*" indicates required fields Step 1 of 6 16% EmailThis field is for validation purposes and should be left unchanged.APPLICANT / BUSINESS ENTITY Business Type* Corporation Limited Liability Co. General Partnership Limited Partnership Sole Proprietorship Name Of Business*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country TelephoneFAXOtherContact Email Business Established Date* MM slash DD slash YYYY State*Charter or Registration No.*Federal ID No.Any trade or assumed business names (registered or not)? Yes No Prior business names used within the last 5 yearsHow did you hear about Pendleton Capital? BUSINESS PROFILE Describe primary business activityHas Applicant or any owner ever filed bankruptcy? Yes No Is there any actual or proposed litigation, or negotiations or filings pursuant thereto, relating to the Applicant or any owner? Yes No Is Applicant current on all Federal and State tax related filings? Yes No Are there any past due Federal or State tax payment obligations relating to Applicant? Yes No Have any of applicant’s owners, shareholders, or partners ever been convicted of a felony? Yes No If Yes, provide detailsOperating facilities Owned Leased Square Ft.Landlord NameTelephoneIf facilities owned, is there a Mortgage? Yes No If Yes, Balance $Est. Market Value $Number of employees (941 kind)If Applicant uses contract labor, provide detailsPROFESSIONAL SERVICE REFERENCES AccountantAttorneyInsurance Agent OWNERSHIP / MANAGEMENT 1) Legal NameMiddleLastPhoneCell PhonePrevious AddressTitleOwnership %Date Of Birth MM slash DD slash YYYY SS No.Private Banker's Name and Tel No.2) Legal NameMiddleLastPhoneCell PhonePrevious AddressTitleOwnership %Date Of Birth MM slash DD slash YYYY SS No.Private Banker's Name and Tel No.3) Legal NameMiddleLastPhoneCell PhonePrevious AddressTitleOwnership %Date Of Birth MM slash DD slash YYYY SS No.Private Banker's Name and Tel No.4) Legal NameMiddleLastPhoneCell PhonePrevious AddressTitleOwnership %Date Of Birth MM slash DD slash YYYY SS No.Private Banker's Name and Tel No. BUSINESS BANKING Bank NameAddressRouting No.Officer or Contact NamePhoneYear Started With BankChecking Acct No.Deposit Acct No.Provide details of all loansSECURED CREDITORS List Secured Transactions and Leases (Credits, Loans and Leases) 1) SecuredParty ContactTelephoneBalanceCollateral2) SecuredParty ContactTelephoneBalanceCollateral3) SecuredParty ContactTelephoneBalanceCollateral VENDOR REFERENCES List primary 3 Vendors A) IndustryVendor NameContactPhoneBalanceCredit LimitB) IndustryVendor NameContactPhoneBalanceCredit LimitC) IndustryVendor NameContactPhoneBalanceCredit LimitACCOUNTS RECEIVABLE INFORMATION A/R Bal1-30 days31-60 daysOver 90 daysAmount invoiced last 30 daysLast 12 monthsNumber of Active customer accounts (AVG)Normal Terms of SaleInvoice sizeHas Applicant ever financed or sold its accts receivable? Yes No Is Applicant or any Owner related to any customer account, in whole or in part? (ownership, parent, subsidiary, partner, affiliate) Yes No Do any of Applicant's accts receivable presently serve as collateral for any purpose? Yes No 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) CustomerAddressContactTelephoneAvg. Sales/mo2) CustomerAddressContactTelephoneAvg. Sales/mo3) CustomerAddressContactTelephoneAvg. Sales/mo4) CustomerAddressContactTelephoneAvg. Sales/mo5) CustomerAddressContactTelephoneAvg. Sales/moDECLARATION 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 NameByNameTitleDate MM slash DD slash YYYY Δ
