EFTA02302943

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 Business Name DBA D Date the Business staled Street Address City. State Zip Code Number of full & part-time employees. 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: Do you offer your product or service on CASH or CREDIT If you offer credit • please specify billing terms: Sales territory is: LOCAL NATIONAL REGIONAL INTERNATI The customers of this business are THE GENERAL PUBLIC COMMERCIAL ACCOUNTS OTHER primarily: 3 - HISTORY OF THE BUSINESS - HOW THE BUSINESS GOT STARTED The legal structure is: Proprietorship Partnership Corporation Other Is trade style registered, YES NO The dollar amount 3 used to start this business was If trade style is registered City/Town Registered This money Loans from S came from: the owners Date incorporated State where incorporated Savings S '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_0 1173952 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 College Degree Received Date Reed % Stock Ownership Title: Year of Birth College Degree Received Date Rec d % Stock Ownership Title: Year of Birth College Degree Received Date Reed % 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 Owner #1 Positrons Held Yr Company Yr Ended Started Name City State Name Owner #1 Positions Held Yr Yr Ended Started Company Name City State 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 Number Contact Person 1 1 2 Signature: Date: EFTA_R1_01173954 EFTA02302945