Primary Information
First Name:
Last Name:
E-mail Address:

Company Information
Company Name:
Company Address :
City:
State:
Zip Code:
Phone # :
Fax :
Years In Business :
Type Of Business :

Principal Owner Information
Principal 1:
Social Security # 1:
Address 1:
City 1:
State 1:
Zip Code 1:
Ownership % 1:
Principal 2:
Address 2:
City 2:
State 2:
Zip Code 2:
Social Security # 2:
Ownership % 2:

Bank References
Bank Name:
Bank Account # :
Bank Phone #:

Equipment & Term
Product:
Retail Cost:
Lease Term:
Vendor Company Name:
Vendor Contact Name:
Vendor Phone #:
Vendor E-mail Address:

How did you find JB2 Funding?

Delivery of this application bearing a facsimile signature(s) shall have the same force and effect as if the application bore an inked original signature(s).

The applicant certifies that all information provided is true, correct and complete and that the account will be used solely for business or commercial purposes.

The applicant, owner(s) and guarantor (if any) authorize JB2 Funding or its designee(s) or assignee(s) to obtain any information it may request from any business or consumer reporting agency(ies) or other sources that provide credit reports, account history information, credit and employment history or similar information; such authorization shall extend to update renewal of credit and for reviewing or collecting the account.

The applicant acknowledges that, based upon such information and other factors which may apply, JB2 Funding or its assignee(s) or designee(s), in their sole discretion, may either grant or decline to grant credit.

By submitting this application, I also wish to continue to receive updates from JB2 Funding regarding my account. Information should be sent to the fax and/or email address given for the account.