western
Finance Application

Form must be filled out completely in order to be processed...
All information is secure and completely confidential.
Customer Info  
Legal Business Name
 		Business Phone No.
DBA * Doing Business As* (if applicable)
 Business Fax No.
Business Street Address
 Contact Name
City e-mail address
State   Zip Tax Identification No.
Description of Business
Years in Business (current owner)
Proprietorship Corporation (State ) General Partnership Limited Partnership Limited Liabilty Company (LLC) State or Local Government
Ownership Info (Owners, partners and/or principals / officers)  
Name
% Ownership
Title
Social Security No.
Home Street Address
 Home Phone No.
City  
State   Zip  
   
Name
% Ownership
Title
Social Security No.
Home Street Address
 Home Phone No.
City  
State   Zip  
Banking Reference  
Bank #1 Name
Account No.
Contact
 Phone No.
Bank #2 Name
Account No.
Contact
 Phone No.
Trade References
Trade Reference #1
 Account No.
Contact
 Phone No.
Trade Reference #2
 Account No.
Contact
 Phone No.
Trade Reference #3
 Account No.
Contact
 Phone No.
Sales Representative
Sales Contact
e-mail address (if available)
Phone No.
Equipment Description
Equipment Installation Location

Check if same as Customer's address		 Financing Amount Requested
$
Manufacturer

Equipment Description

Agreement to Terms

By submitting this application you certify that the information provided in this credit application is accurate and complete. Each individual named below authorizes you or any lender or funding source which may be utilized (collectively referred to as “Lenders”) to obtain information from the references listed above and obtain a consumer credit report that will be ongoing and relate not only to the evaluation and/or extension of the business credit requested, but also for purposes of reviewing the account, increasing the credit line on the account (if applicable), taking collection action on the account, and for any other legitimate purpose associated with the account as may be needed from time to time. Each individual named below further waives any right or claim which such individual would otherwise have under the Fair Credit Reporting Act in the absence of this continuing consent.

Applicant's Name
Signature*
X_________________________________
 Date
Applicant's Name
Signature*
X_________________________________
 Date

*NOTE: Your signature(s) may be required in order to process this application. if so, Horizon Capital will contact you to obtain this.

ECOA NOTICE (TO BE RETAINED BY APPLICANT)
Thank you for your business credit application. We will review it carefully and get back to you promptly. If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain that statement, please contact us within 60 days from the date that you are notified of our decision. We will send you a written statement of the reasons for the denial within 30 days of your request for the statement. NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract), because all or part of the applicant’s income derives from any public assistance program; or because the applicant has, in good faith, exercised any right under the Consumer Credit Protection Act. The federal agency that administers our compliance with this law is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580.

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