atacirShconficienct D&B Business Information Form
atacirShconficienct D&B Business Information Form
Welcome to D&B. The information you provide will be used as a basis for credit.
insurance, marketing and other business decisions. A D&B business analyst may contact
you upon receipt of this completed form to clarify some of the information.
1 - GENERAL INFORMATION
Business Name DBA D Date the Business
staled
Street Address
City. State Zip Code Number of full & part-time employees.
including owners
Mailing Address
Names of Owners/Officers:
1 Tide: Work Phone:
2. This: Far
3. The:
2 - OPERATIONS - A DESCRIPTION OF THE BUSINESS FUNCTION
Describe what the business does:
Do you offer your product or service on CASH or CREDIT If you offer credit • please specify billing terms:
Sales territory is:
LOCAL
NATIONAL
REGIONAL
INTERNATI The customers of this business are
THE GENERAL PUBLIC
COMMERCIAL ACCOUNTS
OTHER primarily:
3 - HISTORY OF THE BUSINESS - HOW THE BUSINESS GOT STARTED
The legal structure is:
Proprietorship
Partnership
Corporation
Other Is trade style registered, YES
NO The dollar amount
3 used to start this business was
If trade style is registered
City/Town
Registered This money
Loans from
S came from:
the owners
Date incorporated
State where incorporated Savings S
'Other S Date registered Please
specify:
4 - FINANCE -A USTING OF THE BUSINESS ASSETS AND LIABILITIES
If this information has been prepared by your accountant, please attach a copy of the financial statement to this form.
Date of the figures below: / / The month the fiscal year ends:
EFTA_R1_0 1173952
EFTA02302943
Date Month
Inventory $ Bank Loans $ Sales for the period
Net Fixtures/Equip. $ Accts Payable $ From to Li
Accounts receivable $ Notes to Owners $ Sales were $
Cash in Bank $ Other Liabilities $
Other Assets $ Monthly Rent $ Profits for the period
Firs Ins. on FtnuresS From 1 i to 1 1
Equipment $ Profits were $
5—BACKGROUND INFORMATION ON THE OWNER(S)! OFFICERS
For the owner(s) outlined in section 1. complete the following (if there are more than 3 owners, attach their resumes to this form):
Owner #1 Owner #2 Owner #3
Title:
Year of Birth
College
Degree Received
Date Reed
% Stock Ownership Title:
Year of Birth
College
Degree Received
Date Rec d
% Stock
Ownership Title:
Year of Birth
College
Degree Received
Date Reed
% Stock Ownership
List previous work experience for each owner from age 21 or back 25 years from the pre t date OR ATTACH RESUME.
Name
Owner #1 Positrons Held Yr Company Yr Ended Started Name City State
Name
Owner #1 Positions Held Yr Yr Ended Started Company
Name City State
EFTA_R1_01173953
EFTA02302944
List other current and/or previous businesses owned for each owner
Owner #1:
Owner #2
Owner #3
Bank Names City State Phone Number Account
Number Contact Person
1 1
2
Signature:
Date:
EFTA_R1_01173954
EFTA02302945