EFTA02302943.pdf

atacirShconficienct D&B Business Information Form Welcome to D&B. The information you provide will be used as a basis for credit. insurance, marketing and other business decisions. A D&B business analyst may contact you upon receipt of this completed form to clarify some of the information. 1 - GENERAL INFORMATION Date the Business D Business Name DBA staled Street Address Number of full & part-time employees. City. State Zip Code including owners Mailing Address Names of Owners/Officers: 1 Tide: Work Phone: 2. This: Far 3. The: 2 - OPERATIONS - A DESCRIPTION OF THE BUSINESS FUNCTION Describe what the business does: If you offer credit • please specify billing terms: Do you offer your product or service on CASH or CREDIT Sales territory is: The customers of this business are primarily: LOCAL THE GENERAL PUBLIC NATIONAL COMMERCIAL ACCOUNTS REGIONAL OTHER INTERNATI 3 - HISTORY OF THE BUSINESS - HOW THE BUSINESS GOT STARTED The legal structure is: Proprietorship Is trade style registered, YES The dollar amount used to start this business was Partnership NO 3 Corporation Other This money came from: If trade style is registered Loans from the owners S Date incorporated City/Town Registered Savings S State where incorporated 'Other S Date registered Please specify: 4 - FINANCE -A USTING OF THE BUSINESS ASSETS AND LIABILITIES If this information has been prepared by your accountant, please attach a copy of the financial statement to this form. Date of the figures below: / / The month the fiscal year ends: EFTA_R1_01173952 EFTA02302943 Date Month Inventory $ Bank Loans $ Sales for the period Net Fixtures/Equip. $ Accts Payable $ From to Li Accounts receivable $ Notes to Owners $ Sales were $ Cash in Bank $ Other Liabilities $ Other Assets $ Monthly Rent $ Profits for the period Firs Ins. on FtnuresS From 1 i to 1 1 Equipment $ Profits were $ 5—BACKGROUND INFORMATION ON THE OWNER(S)! OFFICERS For the owner(s) outlined in section 1. complete the following (if there are more than 3 owners, attach their resumes to this form): Owner #1 Owner #2 Owner #3 Title: Year of Birth Title: Title: Year of Birth College Year of Birth College College Degree Received Degree Received Degree Received Date Reed Date Reed % Stock Ownership Date Rec d % Stock Ownership % Stock Ownership List previous work experience for each owner from age 21 or back 25 years from the pre t date OR ATTACH RESUME. Name Yr Company Positrons Held Yr Ended City State Owner #1 Started Name Name Yr Company Positions Held Yr Ended City State Owner #1 Started Name EFTA_R1_01173953 EFTA02302944 List other current and/or previous businesses owned for each owner Owner #1: Owner #2 Owner #3 Bank Names City State Phone Number Account Contact Person Number 1 1 2 Signature: Date: EFTA_R1_01173954 EFTA02302945