PLEASE PRINT AND THEN FAX THIS COMPLETED APPLICATION TO:  (770) 205-0831

4430 Wellington Place Cumming, Georgia 30040-5246 770-205-6830  •  Toll Free 800-404-6792   Vendor Name: Anything Automotive Address: PO Box 364 Gallatin , Mo. 64640 Telephone: 660-334-0202 Fax: 702-537-1599 Business Legal Name: All Owners: . . Street Address: Home Address: City/State/Zip: City/State/Zip: County: County: Telephone: Telephone: Fax Number: Social Security: Contact Officer: Title: Percentage of Ownership (%): Person Signing Lease: Title: Nature of Business: Proprietorship o    Partnership o    Corporation o    Other o . Years in Business Under Current Ownership: TERMS OF LEASE Federal Tax I.D. #: Equipment Description: Equipment Location: Brand and Model:    o Same as Street Address Total Cost: Lease Terms: FINANCIAL REFERENCES IN BUSINESS NAME ONLY (include banks, leasing companies, equipment or other loans) Reference #1: Checking Acct.#: City/State: Since: Phone: o Lease o Loan Acct#: Contact: Reference #2: Checking Acct.#: City/State: Since: Phone: o Lease o Loan Acct#: Contact: Reference #3: Checking Acct.#: City/State: Since: Phone: o Lease o Loan Acct#: Contact: SUPPLIER REFERENCES Company Name: City/State: Telephone:   Company Name: City/State: Telephone: Company Name: City/State: Telephone: Landlord Name: City/State: Telephone: I hereby authorize UniSource Capital or its assigns to make a complete credit check on our company and the principals of the same and/or guarantors, as individuals, and to relate this information to others as necessary to secure credit approval. I also authorize the above references to release any information that may be requested by UniSource Capital. A fax or photocopy of this authorization shall be valid as the original. I certify this statement is true and accurate. X        Signature Title Date