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APPLICATION TO ENTER INTO ACCOUNTS RECEIVABLE SECURITY AGREEMENT
COPY AND FAX US THIS APPLICATION TO ENTER INTO AN ACCOUNTS RECEIVABLE SECURITY AGREEMENT

COMPANY INFORMATION BUSINESS
NAME:________________________________________________________________________________ As listed on Articles of Incorporation or Partnership Agreement Telephone______________________ Fax________________________ Cell Phone________________________________ Proprietorship ____________ Partnership _____________ Corporation ________________ LLC ____________________ If a corporation, in what state incorporated?_________________________________________________________________ Doing business under other name_________________________________________________________________________ Street Address________________________________________________________________________________________ City ________________ County _____________ State ______ Zip__________ Date Established____________________ If doing business at more than one place, list all additional addresses (list on attachment, if necessary)__________________ ___________________________________________________________________________________________________ E-mail Address:______________________________ Web Address:_____________________________________________ TYPE OF BUSINESS Manufacturer _____ Wholesaler _____ Distributor _____ Service _____ Line of Business __________________________ Describe Business:____________________________________________________________________________________ ___________________________________________________________________________________________________ PREVIOUS BUSINESS NAME(S) used within the past five (5) years _____________________________________ ___________________________________________________________________________________________________ Any subsidiaries or affiliates of business? ______ No ______ Yes If yes, explain______________________________ ___________________________________________________________________________________________________ Has there been a change of ownership in last 12 months? ______ No ______ Yes If yes, explain____________________ ___________________________________________________________________________________________________ Has there ever been a change of business name? ______ No ______ Yes If yes, explain____________________________ ___________________________________________________________________________________________________ Is the company now or has it ever been in bankruptcy? ______ No ______ Yes If yes, explain______________________ ___________________________________________________________________________________________________

TAX INFORMATION FEDERAL TAX
ID___________________________________________________________________ Do you have any Federal or State taxes past due, including but not limited to withholding taxes? _____ Yes ____ No If yes, has any lien been filed? _____ Yes _____ No Any levies filed? _____ Yes ______ No If yes, please list: TYPE:_______________________ QUARTER/YEAR_____________ AMOUNT $________________ Federal $_____________________ Agent Name_________________________Phone______________________________ State $_____________________Agent Name_________________________Phone______________________________ Local $_____________________Agent Name_________________________Phone______________________________ Do you have any payment plans in place? _______ Yes ________ No PRINCIPALS Title__________ Name_________________________________________Home Phone______________________ President, Sole Proprietor, or Home Street Address_____________________________________________________________ Senior Partner City, State, Zip__________________________________________________________________ % Owned______ Social Security No._____________________________ Date of Birth_______________________ Driverís License No._____________________________________________________________ Title__________ Name_________________________________________Home Phone______________________ President, Sole Proprietor, or Home Street Address_____________________________________________________________ Senior Partner City, State, Zip__________________________________________________________________ % Owned______ Social Security No._____________________________ Date of Birth_______________________ Driverís License No._____________________________________________________________ Title__________ Name_________________________________________Home Phone______________________ President, Sole Proprietor, or Home Street Address_____________________________________________________________ Senior Partner City, State, Zip__________________________________________________________________ % Owned______ Social Security No._____________________________ Date of Birth_______________________ Driverís License No._____________________________________________________________ Title__________ Name_________________________________________Home Phone______________________ President, Sole Proprietor, or Home Street Address_____________________________________________________________ Senior Partner City, State, Zip__________________________________________________________________ % Owned______ Social Security No._____________________________ Date of Birth_______________________ Driverís License No._____________________________________________________________



REFERENCES

ACCOUNTANT____________________________Firm______________________Phone___________________ Street Address., City, State, Zip ___________________________________________________________________ Regular Financial Statements Prepared?_______________ How often?_____________ Prepared last?___________ ATTORNEY_______________________________Firm______________________Phone___________________ Street Address, City, State, Zip____________________________________________________________________ Any lawsuits pending? ______ No ______ Yes If yes, explain______________________________________ Any judgments? ______ No ______ Yes If yes, explain_____________________________________________ Do you have any past bankruptcies? ______ No ______ Yes If yes, when_________________________________ BANK______________________________Account Officer___________________Phone____________________ Account Number______________________City & State_______________________________________________
ACCOUNTS RECEIVABLE INFORMATION

Receivable amount open as of ___________ $___________ No. of Accounts_________ Terms of Sale__________ Aging: Current:________ 31-60__________ 61-90___________ 91-120_____________Over 120______________ Total sales last 30 days:________________________ Total sales last 12 months:____________________________ Five (5) Largest Customers Address Phone, Fax MonthlyAverage by Sales Volume Contact Sales Inv. Size ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ___________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Amount you intend to factor on a monthly basis $_______________ Where are remittances mailed?_____________ Have receivables been financed or factored before? ______ No ______ Yes If yes, explain_________________ Are receivables currently financed or factored? ______ No ______ Yes If yes, with whom?_________________ Amount of credit losses last three (3) years: $________________________________________________________ What is your average monthly billing?______________________________________________________________ What is average size invoice? $___________________ Largest $_____________ Smallest $___________________ Are any of your receivables Progress Billing? ______ Yes ______ No Do you fill in ďas completedĒ for larger products? ______ Yes _______ No



Do you have Contra Accounts? (Do you buy and sell from the same account?) ______ Yes _______ No If yes, explain_________________________________________________________________________________ Do you have any Guaranteed Sales? _______ Yes _______ No Do you have any active UCC Filings on your receivables? (Are your receivables pledged as collateral?) Yes ________ No ________ If yes, with whom_____________________________________________________ Do you have any outstanding business loans? _______ Yes _______ No If yes, with whom______________________________________________________________________________ Loan Amount $___________________________ Term________________________________________________ Do you have any other company assets pledged as collateral (inventory, buildings)? ______ Yes _______ No If yes, with whom______________________________________________________________________________ PRINCIPAL SUPPLIERS Name of Supplier Product Supplied Contact Phone Number ____________________________ ______________________ ____________________ _________________ ____________________________ ______________________ ____________________ _________________ ____________________________ ______________________ ____________________ _________________
Date:_______________________________ Applicant:_________________________________________ By:_______________________________________________ Its:_______________________________________________



ADDENDUM TO CREDIT APPLICATION

The undersigned individual(s) who is/are either a principal(s) of the credit application or a sole proprietorship of the credit applicant, recognizing that his other individual credit history may be a factor in the evaluation of the credit history of the applicant, hereby consents to and authorizes the use of a consumer credit report on the undersigned the Financial source Corporation, from time to time as may be needed in the credit evaluation. ____________________________________ __________________________________________ ____________________________________ __________________________________________ Date:_______________________________
CHECKLIST
(Please enclose with application)
1. Corporate or personal tax returns (2 years)
2. Corporate or personal financial statements (2 years)
3. Articles of Incorporation (if corporation)
4. Partnership Agreement (if partnership)
5. Current aging of accounts receivables
6. Current aging of accounts payable
7. Copies of any UCC Filings if you presently have assigned your accounts receivable to another secured party.



CURTIS ROSS
1-843-746-9666 PHONE
1-843-746-8918 FAX