Polen's BuyBid Auto Exchange Inc.

Financial Information Request


Type of EntityDate




As Partner or President of the Company I am applying for this Floor-plan Line, completing and signing this application.

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Company Legal NameTax ID NumberSales Tax Number

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If DBA, List DBA NameTax ID NumberSales Tax Number



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Business Address    CityStateZipBusiness PhoneBusiness Fax


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Mailing Address       CityStateZipBusiness Email Address



1._____________________________________________/_______________________________/___________________

Names of Company Partners or Officer if Inc.Driver's License NumberExpiration Date

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Date of BirthSocial Security NumberCell Phone NumberPersonal Email Address



2._____________________________________________/_______________________________/___________________

Names of Company Partners or Officer if Inc.Driver's License NumberExpiration Date

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Date of BirthSocial Security NumberCell Phone NumberPersonal Email Address



3._____________________________________________/_______________________________/___________________

Names of Company Partners or Officer if Inc.Driver's License NumberExpiration Date

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Date of BirthSocial Security NumberCell Phone NumberPersonal Email Address

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Do you Own or Rent?

Business Location Home Location


Business Type:


Years in Business Years at current location License Number: F/P limit requested $



Name 3 Business Reference:

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Company NameBusiness TypePhoneWho is your contact here?



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Company NameBusiness TypePhoneWho is your contact here?



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Company NameBusiness TypePhoneWho is your contact here?





If this is a partnership both partners must give the following information and sign.


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Full Name Owner, Partner or PresidentOwnership %Personal AddressCityStateZip



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Full Name Owner, Partner or PresidentOwnership %Personal AddressCityStateZip





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Authorization and Consent


The owner, partners, or officers hereafter the (Principles) hereby certify that the information contained within this application is true, complete, and accurately reported. The Principles herein authorize Polen's BuyBid Auto Exchange Inc. hereafter (PBAE) to obtain credit information and/or background information from credit bureaus and any financial institution or trade creditor that the Principles have provided or any other source which PBAE deems appropriate and necessary. Principles also authorize PBAE to contact any third parties and to disclose information limited to assessing Principles credit worthiness, collection of any outstanding debt, and obtaining any prior financial agreements as to perfect PBAE's Blanket Security Agreement further, if credit is granted, Principles authorize PBAE to review Principles account periodically, which could include obtaining additional credit reports. Principles authorize PBAE to disclose my credit information into any credit database. Principles authorize PBAE, to call, fax, email or text Principles for the purposes of including, but not limited to marketing, collection and any other communication needs. Principles understand and agree that this application will not be complete until PBAE receives the information it regularly obtains and considers when it evaluates applications for the amount and type of floor-plan Principles are requesting. PBAE will notify Principles if it requires Principles to provide any information or documents in addition to those expressly requested by this application.


The Floor-plan Line Collateral Is a Blanket Security Agreement sent after application approval for your review and signature.

Please review your application information before printing and signing.

I HAVE READ THE AUTHORIZATION AND CONSENT AND I UNDERSTAND AND AGREE TO THESE TERMS.

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Owner, Partner or Presidents NameSignatureDate




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Owner, Partner or Presidents NameSignatureDate



A clear copy of Owner, Partner or officers driver's License's must accompany this Application.

After completing this application please print and fax to 217-935-9600 or mail to:

Polen's BuyBId Auto Exchange
8033 Walnut Rd
Clinton IL. 61727

After your application is approved we will email you our Demand Promissory Note and Security Agreement. Please complete and sign the security agreement and mail to:

Polen's BuyBId Auto Exchange
8033 Walnut Rd
Clinton IL. 61727


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Date


Formal request for and authorization to release Information


I Principle of


am authorizing Polen's BuyBid Auto Exchange Inc. to receive answers to and my bank listed below to respond to the following questions.


Bank Name:     Bank Contact:


Bank Contacts Email: 


Account #:        Bank Phone Bank Fax



Information Requested:


Is this account in good standing and current with all its obligations to your bank?     YES   NO


Has this account written any ISF checks in the past 24 months?    YES   NO


What is the last 3 months' average balance pertaining to this account? $



Requested by: Polen's BuyBid Auto Exchange      Agent:____________________________________________________

Signature


Authorized by:    Principle: ________________________________________________

Signature

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