Vendor Name:

Salon Services.net & American Quality MFG, Cocoa, FL

Tanning Bed Equipment Description:         (please circle)

Vendor Contact

Rick Houston

Vendor Phone:

(888) 999-7577

Vendor Fax:

(866) 237-4208

Full Legal Name

Home Address

City, State, Zip:

Home Phone:

Employment:

How long?

Annual Income

Work Phone:

Employment address:

Date of Birth

Social Security Number

Email Address:

Have you filed bankruptcy in the past 7 years? if so, when:

Mobile Phone Number:

Bank:

Phone #:

Account #:

Contact:

Bank:

Phone #:

Account #:

Contact:

Company/Personal Reference Name:

Phone #:

Account #:

Contact:

Company/Personal Reference Name:

Phone #:

Account #:

Contact:

Delivery of this application bearing a facsimile signature(s) shall have the same force and effect as if the application bore an inked original signature(s).  The applicant certifies that all information provided is true, correct and complete and that the account will be used solely for business or commercial purposes.  The applicant, owner(s) and guarantor (if any) authorize First Funding or its designee(s) or assignee(s) to obtain any information it may request from any business or consumer reporting agency(ies) or other sources that provide credit reports, account history information, credit and employment history or similar information; such authorization shall extend to update renewal of credit and for reviewing or collecting the account.  The applicant acknowledges that, based upon such information and other factors which may apply, Direct Capital or its assignee(s) or designee(s), in their sole discretion, may either grant or decline to grant credit. By signing below, I also wish to continue to receive updates from First Funding regarding our account. Information should be sent to the fax and/or email address given for the account.

Applicant's Signature  _________________________________________________ Date _______________