APPLICATION

Required (*)
COMPANY INFORMATION
BUSINESS NAME:		*
BUSINESS ADDRESS:		*
CITY:		*
STATE:	- Select One - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	*
ZIP CODE:		*
TAX ID NUMBER:
WORK PHONE:	( ) -	*
FAX:	( ) -
E-MAIL:
YEARS IN BUSINESS:		*
TYPE OF BUSINESS:	Corporation Sub S-Corporation Proprietorship Partnership LLC PA/PC Non-Profit	*

1. BANK REFERENCE
BANK:		*
PHONE:	( ) -	*
CONTACT:		*
ACCOUNT #:
2. BANK REFERENCE
BANK:
PHONE:	( ) -
CONTACT:
ACCOUNT #:

TRADE REFERENCE
COMPANY:		*
PHONE:	( ) -	*
CONTACT:		*
ACCOUNT #:
2nd TRADE REFERENCE
COMPANY:		*
PHONE:	( ) -	*
CONTACT:		*
ACCOUNT #:
3rd TRADE REFERENCE
COMPANY:
PHONE:	( ) -
CONTACT:
ACCOUNT #:

OWNERSHIP & PRINCIPAL INFORMATION
NAME:		*
TITLE:		*
OWNERSHIP (%):		*
HOME ADDRESS:		*
CITY:		*
STATE:	- Select One - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	*
ZIP:		*
HOME PHONE:	--	*
SOCIAL SECURITY #:	--	*
2nd OWNERSHIP INFORMATION
NAME:
TITLE:
OWNERSHIP (%):
HOME ADDRESS:
CITY:
STATE:	- Select One - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
ZIP:
HOME PHONE:	--
SOCIAL SECURITY #:	--

VENDOR/SUPPLIER INFORMATION
COMPANY'S NAME:
CONTACT:
PHONE:	( ) -

EQUIPMENT DESCRIPTION:		*
AMOUNT REQUESTED:$		*
TERM:	24 Months 36 Months 48 Months 60 Months
PURCHASE OPTION:	One Dollar Fair Market Value 10% Option 10% Guaranty 20% Guaranty TRAC Lease
COMMENTS:
My signature below will serve as authorization to release information regarding my account(s) to ACI Financial, Inc.

ACI Financial, Inc.
2662 Holcomb Bridge Road, Suite 314
Alpharetta, Georgia 30022
Phone Number (770) 390-9400
Toll-Free (800) 648-6477
Fax Number (770) 394-1777
info@acifinancial.com