Secure On-Line Vendor Profile

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Your Contact at US Financial Group
Attention To:

Company Information
Years in Business:  Years at this Location:  
Years of Experience:  Number of Employees: 
Avg # of Sales Per Mo: Avg Monthly Volume:   
Type of Company:  Proprietorship Partnership Corporation
Date Incorporated:
Full Legal Name:
Doing Business As:
Address: 
City: State: Zip:
Phone: 
Fax Number: 
Mobile Phone: 
Email Address: 
Mailing Address & Zip: 
Federal ID Number:  Resale Number:
Equipment Lines
Primarily Sold:  
If Any Previous
Credit Problems
Please Explain: 
Comments:  

Principals of Company: Owner, Partners, President and etc.

Full Name & Title:  
Home Address & Zip:  
Home Phone:    Social Security No:

Full Name & Title:  
Home Address & Zip:  
Home Phone:    Social Security No:

Banking & Checking Information

Bank's Name:  
Address & Zip:  
Acct Type:    Acct No:  
Phone:    Contact:  

Bank's Name:  
Address & Zip:  
Acct Type:    Acct No:  
Phone:    Contact:  


Current Trade References

Name:  
Address & Zip:  
Phone:    Contact:  

Name:  
Address & Zip:  
Phone:    Contact:  

Current Funding Sources

Name:  
Address & Zip:  
Phone:    Contact:  

Name:  
Address & Zip:  
Phone:    Contact:  

Statement of Understanding and Authorized Signature

I hereby represent and warrant that I am duly authorized to provide this information on behalf of my company. I agree that when I type my name, in the text box below, that for all intent and purposes I will be providing my legal signature over the internet to US Financial Group. I further agree that the legal ramifications are the same as if I actually signed this document in the presence of a US Financial Group representative.

This information is being provided to secure funding for our equipment sales. I grant permission to US Financial Group to obtain a personal credit report (bureau) on all of the individuals that are listed above. I understand that individual credit histories may be a determining factor in the evaluation of this request.

I authorize the bank and business references listed above, as well as any of my/our lessors, landlords and any other past or present creditors to give any and all necessary information to US Financial Group, or to their assignees or transferees, which will assist in the evaluation of this request.

I hereby certify under penalty of law that all of the foregoing information is true.

Please note: Consideration will "not" be given by US Financial Group unless you have typed your name and title below, which comprises your electronic signature for internet transmitted documents.

(Type: Full Legal Name, Title)