RER Capital Funding
Credit Application
	
SUPPLIER INFORMATION	
VENDOR NAME	CONTACT	PHONE	FAX	

			
			
LEGAL COMPANY NAME               	ADDRESS 	CITY	STATE	WORK PHONE	FED. TAX I.D. #

CONTACT PERSON	TYPE OF BUSINESS			
	CORPORATION	PROPRIETORSHIP	PARTNERSHIP	
# OF YEARS IN BUSINESS UNDER CURRENT OWNERSHIP		DESCRIPTION OF BUSINESS	
			
BILLING ADDRESS (IF DIFFERENT FROM ABOVE)	CITY	STATE	ZIP	
				
EQUIPMENT & LEASE INFORMATION	
DESCRIPTION OF PRODUCT	PRODUCT COST

			
				
PERSONAL DATA	
NAME	HOME ADDRESS	CELL NUMBER	
			
CITY	STATE	ZIP	SOCIAL SECURITY #	
				
TITLE	% OWNERSHIP	E-MAIL ADDRESS	
			
NAME	HOME ADDRESS	CELL NUMBER	
			
CITY	STATE	ZIP	SOCIAL SECURITY #	
				
TITLE	% OWNERSHIP	E-MAIL ADDRESS	
			
REFERENCE DATA	
LIST PRESENT BANK(S) - PREVIOUS BANK IS REQUIRED IF APPLICANT HAS BEEN AT PRESENT BANK LESS THAN TWO YEARS	
PRESENT BANK OF APPLICANT	PREVIOUS OR SECOND BANK OF APPLICANT	
		
BRANCH	PHONE	BRANCH	PHONE	
				
NAME OF BANK OFFICER	ACCT. #	NAME OF BANK OFFICER	ACCT. #	

By signing below, the individual submitting this form, recognizing that his/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.
 I hereby authorize our banks, trade references, and financial institutions the right to release credit information over the phone.

DATE: ________________

Signature: X	

RER Capital Funding	100 Broadway  Ste 206  Massapequa, NY  11758
Tel.: 631-957-7825    www.rercapitalfunding.com    Fax: 631-957-7840 
email: services@rercapitalfunding.com