Business Name
DBA
Address
City
State
-- SELECT --
Alabama [AL] Alaska [AK] American Samoa [AS] Arizona [AZ] Arkansas [AR] California [CA] Colorado [CO] Connecticut [CT] Delaware [DE] District of Columbia [DC] Federated States of Micronesia [FM] Florida [FL] Georgia [GA] Guam [GU] Hawaii [HI] Idaho [ID] Illinois [IL] Indiana [IN] Iowa [IA] Kansas [KS] Kentucky [KY] Louisiana [LA] Maine [ME] Marshall Islands [MH] Maryland [MD] Massachusetts [MA] Michigan [MI] Military Americas, Florida, [AA] Military California, Pacific [AP] Military International, New York [AE] Minnesota [MN] Mississippi [MS] Missouri [MO] Montana [MT] Nebraska [NE] Nevada [NV] New Hampshire [NH] New Jersey [NJ] New Mexico [NM] New York [NY] North Carolina [NC] North Dakota [ND] Northern Mariana Islands [MP] Ohio [OH] Oklahoma [OK] Oregon [OR] Palau [PW] Pennsylvania [PA] Puerto Rico [PR] Rhode Island [RI] South Carolina [SC] South Dakota [SD] Tennessee [TN] Texas [TX] Utah [UT] Vermont [VT] Virgin Islands [VI] Virginia [VA] Washington [WA] West Virginia [WV] Wisconsin [WI] Wyoming [WY]
Zip
County
If using a DBA, what County was the Fictitious Business Name Statement filed?
If more than one place, list the counties, cities, and states where any and all business activities are conducted.
Type of Business
-- SELECT --
Individual Partnership Corporation
If a corporation, what State of Incorporation?
-- SELECT --
Alabama [AL] Alaska [AK] American Samoa [AS] Arizona [AZ] Arkansas [AR] California [CA] Colorado [CO] Connecticut [CT] Delaware [DE] District of Columbia [DC] Federated States of Micronesia [FM] Florida [FL] Georgia [GA] Guam [GU] Hawaii [HI] Idaho [ID] Illinois [IL] Indiana [IN] Iowa [IA] Kansas [KS] Kentucky [KY] Louisiana [LA] Maine [ME] Marshall Islands [MH] Maryland [MD] Massachusetts [MA] Michigan [MI] Military Americas, Florida, [AA] Military California, Pacific [AP] Military International, New York [AE] Minnesota [MN] Mississippi [MS] Missouri [MO] Montana [MT] Nebraska [NE] Nevada [NV] New Hampshire [NH] New Jersey [NJ] New Mexico [NM] New York [NY] North Carolina [NC] North Dakota [ND] Northern Mariana Islands [MP] Ohio [OH] Oklahoma [OK] Oregon [OR] Palau [PW] Pennsylvania [PA] Puerto Rico [PR] Rhode Island [RI] South Carolina [SC] South Dakota [SD] Tennessee [TN] Texas [TX] Utah [UT] Vermont [VT] Virgin Islands [VI] Virginia [VA] Washington [WA] West Virginia [WV] Wisconsin [WI] Wyoming [WY]
How did you hear about BH Capital?
Open Balance
$
Factored Before
01 02 03 04 05 06 07 08 09 10 11 12
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Source
Approx. No. of Accounts
Terms of Sale
Average Mo. Sales Volume
$
Average Mo. No. of Invoices
Do any customers buy from you on a "Contra" account basis?
-- SELECT --
Yes No
Type of Equipment to be Financed
Current Depreciated Value of Equipment
$
Current Market Value of Equipment
$
Value of Equipment to be Purchased
$
Appraised Value of Real Estate to be Financed
$
Purchase Price of Real Estate
$
Assets to be Pledged as Security for Line of Credit
Assets to be Pledged for Term Loan
Bank Name
Type of Account
-- SELECT --
Checking General Checking Payroll Automatic Overdraft Coverage Savings Certificate of Deposit Other
Address
City
State
-- SELECT --
Alabama [AL] Alaska [AK] American Samoa [AS] Arizona [AZ] Arkansas [AR] California [CA] Colorado [CO] Connecticut [CT] Delaware [DE] District of Columbia [DC] Federated States of Micronesia [FM] Florida [FL] Georgia [GA] Guam [GU] Hawaii [HI] Idaho [ID] Illinois [IL] Indiana [IN] Iowa [IA] Kansas [KS] Kentucky [KY] Louisiana [LA] Maine [ME] Marshall Islands [MH] Maryland [MD] Massachusetts [MA] Michigan [MI] Military Americas, Florida, [AA] Military California, Pacific [AP] Military International, New York [AE] Minnesota [MN] Mississippi [MS] Missouri [MO] Montana [MT] Nebraska [NE] Nevada [NV] New Hampshire [NH] New Jersey [NJ] New Mexico [NM] New York [NY] North Carolina [NC] North Dakota [ND] Northern Mariana Islands [MP] Ohio [OH] Oklahoma [OK] Oregon [OR] Palau [PW] Pennsylvania [PA] Puerto Rico [PR] Rhode Island [RI] South Carolina [SC] South Dakota [SD] Tennessee [TN] Texas [TX] Utah [UT] Vermont [VT] Virgin Islands [VI] Virginia [VA] Washington [WA] West Virginia [WV] Wisconsin [WI] Wyoming [WY]
Zip
Contact
Name of Attorney
Attorney's Telephone
( )
-
Name of Accountant
Accountant's Telephone
( )
-
Name
Telephone
( )
-
Name
Telephone
( )
-
Name
Telephone
( )
-
Are any assets now assigned, pledged or liened as collateral for loans?
-- SELECT --
Yes No
If Yes, To Whom?
Personal Information - Owner or Officers - Residence
[ Back to Top ]
Name
Title
Address
City
State
-- SELECT --
Alabama [AL] Alaska [AK] American Samoa [AS] Arizona [AZ] Arkansas [AR] California [CA] Colorado [CO] Connecticut [CT] Delaware [DE] District of Columbia [DC] Federated States of Micronesia [FM] Florida [FL] Georgia [GA] Guam [GU] Hawaii [HI] Idaho [ID] Illinois [IL] Indiana [IN] Iowa [IA] Kansas [KS] Kentucky [KY] Louisiana [LA] Maine [ME] Marshall Islands [MH] Maryland [MD] Massachusetts [MA] Michigan [MI] Military Americas, Florida, [AA] Military California, Pacific [AP] Military International, New York [AE] Minnesota [MN] Mississippi [MS] Missouri [MO] Montana [MT] Nebraska [NE] Nevada [NV] New Hampshire [NH] New Jersey [NJ] New Mexico [NM] New York [NY] North Carolina [NC] North Dakota [ND] Northern Mariana Islands [MP] Ohio [OH] Oklahoma [OK] Oregon [OR] Palau [PW] Pennsylvania [PA] Puerto Rico [PR] Rhode Island [RI] South Carolina [SC] South Dakota [SD] Tennessee [TN] Texas [TX] Utah [UT] Vermont [VT] Virgin Islands [VI] Virginia [VA] Washington [WA] West Virginia [WV] Wisconsin [WI] Wyoming [WY]
Zip
Telephone
( )
-
% Ownership
Own or Rent?
-- SELECT --
Own Rent
Driver's License #
State of Driver's License
-- SELECT --
Alabama [AL] Alaska [AK] American Samoa [AS] Arizona [AZ] Arkansas [AR] California [CA] Colorado [CO] Connecticut [CT] Delaware [DE] District of Columbia [DC] Federated States of Micronesia [FM] Florida [FL] Georgia [GA] Guam [GU] Hawaii [HI] Idaho [ID] Illinois [IL] Indiana [IN] Iowa [IA] Kansas [KS] Kentucky [KY] Louisiana [LA] Maine [ME] Marshall Islands [MH] Maryland [MD] Massachusetts [MA] Michigan [MI] Military Americas, Florida, [AA] Military California, Pacific [AP] Military International, New York [AE] Minnesota [MN] Mississippi [MS] Missouri [MO] Montana [MT] Nebraska [NE] Nevada [NV] New Hampshire [NH] New Jersey [NJ] New Mexico [NM] New York [NY] North Carolina [NC] North Dakota [ND] Northern Mariana Islands [MP] Ohio [OH] Oklahoma [OK] Oregon [OR] Palau [PW] Pennsylvania [PA] Puerto Rico [PR] Rhode Island [RI] South Carolina [SC] South Dakota [SD] Tennessee [TN] Texas [TX] Utah [UT] Vermont [VT] Virgin Islands [VI] Virginia [VA] Washington [WA] West Virginia [WV] Wisconsin [WI] Wyoming [WY]
Social Security Number
Date of Birth
01 02 03 04 05 06 07 08 09 10 11 12
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Please submit the following documents as is applicable to your financing request. The more complete the submission the more complete analysis BH Capital Ltd can give you and thus successfully complete your request. Please forward this information to:
BH Capital Limited LLC
2527 Virginia NE Suite J
Albuquerque, NM 87110
USA
In order to quickly determine if we can be of service to your firm, we need all of the information requested above as well as this completed application. If any information requested is not available, please attach a written explanation. All information will be held in strictest confidence. Please forward this information to:
BH Capital Limited LLC
2527 Virginia NE Suite J
Albuquerque, NM 87110
USA
Please tab each item in a comb or three ring binder along with index. We will begin review as soon as we receive the data in its entirety.
By checking this box and entering your e-mail address in the space below, the undersigned certifies the following: That the information set forth in this application and in the documents, schedules, reports, statements, and/or other information provided to BH Capital Ltd with or pursuant to this application are full, true, correct and complete and accurately reflect such information on the date(s) thereof; that BH Capital Ltd is authorized to request, receive and verify credit reports and other financial information regarding applicant and its business that BH Capital Ltd deems necessary or appropriate; that BH Capital Ltd is authorized to inquire of, investigate, confirm, and verify any information contained in this application, in any documents, schedules, reports, statements and/or otherinformation provided under or pursuant to this application or learned by BH Capital Ltd as part of its investigation and review of this application, applicant, or applicant's business.
E-mail Address: