quail capital

Broker Application

Please fill out the form below. Or you can download a printable application.

COMPANY INFORMATION

Company Name:
Company Address:
Email:
City:
State:
Zip:
Signor:
Telephone #:
Fax #:
Tax ID #:
Nature of Business:
Start Date of Business:

INFORMATION ON OFFICERS, PARTNERS OR GUARANTORS

Principal's Legal Name:
Title:
DOB:
SSN:
% Ownership:
Home Address:
City:
State:
Zip:
How long at this address?
Own home?

Principal 2's Legal Name:
Title:
SSN:
% Ownership:
Home Address:
City:
State:
Zip:
How long at this address?
Own home?

COMPANY BANK REFERENCE

Name of Bank/Branch:
How Long:
Telephone #:
Contact Officer:

Name of Bank/Branch:
How Long:
Telephone #:
Contact Officer:

FUNDING SOURCE REFERENCE

Lender:
Telephone #:
Date Began:
Annual Volume $:
	Broker: Discounter:

Lender:
Telephone #:
Date Began:
Annual Volume $:
	Broker: Discounter:

Lender:
Telephone #:
Date Began:
Annual Volume $:
	Broker: Discounter:

MARKETING INFORMATION

Equipment Types:
# of Employees:
Average Monthly Volume $:
Geographic Market:
State:
Bureau Reports Used:	CBI Experian Trans Union
Scoring Models Used:	Beacon / DAS FICO / BRS / NRS EMPIRICA
Contact Person:
Equipment Cost (ex. $55,000):
Equipment Type:
Desired Lease Term:
Insurance Company:
Agent Name:
Telephone #:

DECLARATION

The information contained on this application, together with any accompanying financial statements, schedules or other materials, is submitted to Quail Capital Corp for the purpose establishing a broker/lessor relationship and is warranted to be true, correct and complete. The undersigned individual, recognizing that his or her individual credit history may be a factor in the evaluation of the credit of the applicant, hereby consents to and authorizes the above named business credit provider and any assignee, lender or funding service that may be utilized to obtain and use a consumer credit report on the undersigned, now and from time to time, as may be needed in the credit evaluation and review process and waives any right or claim they would otherwise have under Fair Credit Reporting Act in the absence of this continuing consent.

QUAIL CAPITAL CORP
888/44QUAIL
(888/447-8245)