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* Your Name:

* Company Name:

* Company Address:

* Company City:

* Company State:

* Company Zip:

* Company Type:

* Federal Tax ID:

* Email:

* Your Product or Service:

* Monthly Sales:

* Current account receivables:

Phone:

Fax:

Other information or comments:

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.