* First name: 

* Last Name:  

* Email: 

* Company Name: 

Address: 

City: 

State:         Zip: 

* Company Type:  --None-- Corporation LLC Partnership Sole Proprietorship

Federal Tax ID: 

Please describe your product or service in the box below :

   

Monthly Sales: 

* Current Receivables: 

* Phone: 

Fax: 

By clicking the "Submit" button, I hereby certify that all information provided on this Application is accurate and complete to the best of my knowledge. I authorize Business to Business Capital Corp. to procure credit reports, verifications, and other information which, in its sole discretion, is deemed appropriate for completing its credit evaluation. I provide authorization, on a continuing basis, for any person or business to release any and all credit reports or verifications to Business to Business Capital Corp. I further authorize Business to Business Capital Corp. to file UCC financing statements and amendments to secure any indebtedness which may be incurred as a result of this application.