Please complete all questions and submit form below. PERSONAL INFORMATION First Name*Middle Intial*Last Name*Social Security #*Ownership %*Date of Birth* Title*Mobile Number*Email* Home Address*City*State*Zip Code*Will there be an additional guarantor*YesNo BUSINESS INFORMATION Legal Company Name*DBA*Type of BusinessLLCINCSOLE PROPTime in business*Federal Tax ID #*Email Address* Business Address*City*State*Zip Code*Phone Number*Fax Number EQUIPMENT INFORMATION Amount*Terms*36 Months48 Months60 MonthsEquipment Description*Upload quote Applicant hereby authorizes the release of business and/or personal credit information to Reliant Capital, its affiliates, and referral finance partners, (1) from any source including credit bureau reporting agencies and applicants bank for the purpose of extending credit, (2) to any credit reporting agency. I hereby represent all information is true, correct, and complete. A photo static and/or facsimile copy of this authorization shall be valid as the original. If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact: Credit Operations, Reliant Capital, within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement. NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applications on the basis of race, color, religion, national origin, sex, marital status, age (providing the applicant has the capacity to enter into a binding contact), because of all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The Federal Agency that administers compliance with this law concerning this creditor is: Federal Reserve Consumer Help Center, PO Box 1200, Minneapolis, MN 55480 Section Break This iframe contains the logic required to handle AJAX powered Gravity Forms.