Referral Agent Application | North Mill Equipment Finance LLC

Business Name (DBA if Applicable)*

Business Address *

City *

State *

Zip Code *

Email *

Name of Person Completing Application *

Federal Tax ID # (FEIN) *

Business Founded *

Business Phone Number *

State Where Business is registered

Business Website *

Expected Small Ticket volume (This Year) *

Number of Employees *

Average Deal Size *

Credit Type Financed (Select all that apply) *

Annual Revenue

How did you hear about us ? *

Owner's First Name *

Owner's Last Name *

Owner's Home Address *

Owner's City *

Owner's State *

Owner's Zip Code *

Owner's Cell Phone Number *

Years of Experience in Equipment Financing *

Any Formal Equipment Finance Training, i.e, Course Taken, Prior Experience at Other Brokerage * ( 255 )

Are you currently financing working capital? *

Yes

Interested in discounting ? *

Yes

The undersigned certifies that the information shown above is complete and correct. By signing below, the undersigned agrees to allow North Mill Equipment Finance, LLC and its financing sources and assignees to obtain information in connection with this application and the contemplated transaction(s) from any credit reporting agency or credit provider at any time.

Applicant Electronic Signature*

Title* ( 40 )

Date*