EmailMe Form - Business Credit Line Application

A4 Account Number *

If you are not currently an A4 customer, please complete the new customer application at https://www.a4.com/myaccount/registerdealer

Business Name *

Business Phone Number *

### - ### - ####

Business Type *

Fictitious Business Name (DBA)

Detailed Description of Business *

Amount of Credit Line Requested? *

Contact Email Address *

Business Principals

First Principal Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Social Security Number *

% of Ownership *

Second Principal Name (if applicable)

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Social Security Number

% of Ownership

Third Principal Name (if applicable)

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Social Security Number

% of Ownership

Bank References

Bank Name *

City *

Phone *

### - ### - ####

Fax

### - ### - ####

Name *

First Last

Account Number *

Account Type *

Loan

Deposit

Bank Name (2nd Reference)

City

Phone

### - ### - ####

Fax

### - ### - ####

Contact Name

First Last

Account Number

Account Type

Loan

Deposit

Trade Credit References

Please provide three references from business partners that have extended you credit.

First Reference Name *

Account Number *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

Second Reference Name

Account Number

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Email

Third Reference Name

Account Number

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone

### - ### - ####

Email

Section Break

A description of the section goes here.

Are there any lawsuits, judgements, or liens pending against the business, any of its principal owners, or partners, or any of its affiliates? *

Has the business or any of its affiliates principal owners or partners ever been in any form of bankruptcy? *

Are there any subsidiaries of affiliated companies? *

If yes was answered to any of the above, please explain

In connection with this application, the undersigned herby certifies that the above statements, which are submitted for the purpose of obtaining credit, are true, correct and complete. Moshay Inc., DBA A4, is authorized to make inquiries and gather information the bank feels necessary and reasonable concerning statements made on this application. It is further agreed that Moshay Inc. will promptly be notified of any material changes in the above information.

Electronic Signature

Name *

First Last

Date *

MM / DD / YYYY

Title *

Signature *

Clear

Name

First Last

Date

MM / DD / YYYY

Title

Signature

Clear

Electronic Signature Agreement

I Accept

By Selecting the "I accept" button, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.