Application - Coastal Kapital

Legal Business Name *

Date of Birth *

Business Type *

Physical Business Address *

City *

Dropdown *

Zip Code *

Email *

Email

Confirm Email

Federal Tax ID #

Legal Structure

# Of Employees

Owner Name *

Owner Title *

Owner Date of Birth

Owner Home Address *

City *

State *

Zip Code *

Social Security #

% Of Ownership

0% ownership

Are There Additional Owners?

Yes
No

Second Owner Name

Second Owner Title

Second Owner Date of Birth

Second Owner Home Address

Second Owner City

Second Owner State

Second Owner Zip Code

This is the Second owner Zip Code

Second Owner Social Security #

Second Owners % of Ownership

0% ownership

Is There a 3rd Owner?

Yes
No

Third Owner Name

Third Owner Title

3rd Owner Date of Birth

Third Owner Home Address

Third Owner City

Third Owner State

Third Owner Zip Code

This is the Second owner Zip Code

Third Owner Social Security #

Third Owners % of Ownership

0% ownership

Business Bank Name

Account #

Contact

Trade Reference #1

Trade Reference #2

Vendor Name

Sales Person

Equipment Description

Equipment Condition

New
Used

Price

Term Requested

Checkboxes *

Signature

* I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the best of my knowledge the above information is complete and correct