Your business must have been operating and under existing ownership for at least two years. Only businesses in the US are eligible to apply.

	Company Information   Legal Name of Company DBA   Street Address Federal Tax ID     Years in Business   City Nature of Business   State - Select state - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 Phone # - -   Zip Fax # - -   Business Structure Corporation Proprietorship Partnership

	Trade References 1) Name of References Contact Person or Account Number   phone # - - Fax # - - 2) Name of References Contact Person or Account Number   phone # - - Fax # - - 3) Name of References Contact Person or Account Number   phone # - - Fax # - -

	Bank References Name of Primary Bank phone # - - Contact Person Name of Second Bank phone # - - Contact Person

	Ownership Information 1) Name Company Title   Street Address % ownership %     City       State - Select state - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 2) Name Company Title   Street Address % ownership %     City       State - Select state - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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

	- Release / Authorization - By submitting this application I hereby authorize FX Financial and its assigns to obtain business as well as personal information regarding my credit history via banks, credit reporting companies, and any other extenders of credit. If this application has been completed by someone other than the applicant/principal owner, such person has advised the applicant/principal owner of FX Financial's right to obtain business as well as personal information regarding credit history via banks, credit reporting companies, and any other extenders of credit. You must check the following in order to continue: Applicant / Principal has completed the application or Applicant has been advised of FX Financial's rights as outlined above.