<p> JLuxFunding, LLC </p><p>Secure SSL Transaction this is a secure online finance application. We take great care to protect the information you supply on this site by encrypting it. If you'd rather fax your application. What type of company is this application for? Public Private Borrower/Lessee Vendor Company Name: Company Name: D/B/A: Address: (Doing Business As) City, State & Zip: Address: Telephone: * City, State & Zip: xxx-xxx-xxxx Telephone: Fax: * * xxx-xxx-xxxx xxx-xxx-xxxx Contact Name: Contact: Direct Line: e-Mail: * xxx-xxx-xxxx e-Mail: Bank Reference Fax: * Principal Bank: xxx-xxx-xxxx Account Number: Fed Tax ID: * Telephone: xx-xxxxxxx * xxx-xxx-xxxx D&B #: Contact: (Dun & Bradstreet) State of Incorporation / Organization: Additional Comments Website: Business Description: Time in Business (Years): S-Corp LLC Type of Business: Proprietorship Partnership C-Corp Non-profit * </p><p>Personal Information on Officers, Partners or Owners Name: Name: Home Address: Home Address: City, State & Zip: City, State & Zip: Telephone: Telephone: * * xxx-xxx-xxxx xxx-xxx-xxxx Social Security #: Social Security #: * * xxx-xx-xxxx xxx-xx-xxxx % Ownership: * % Ownership: * </p><p>Trade References Company Name: Company Name: Telephone: Telephone: * * xxx-xxx-xxxx xxx-xxx-xxxx Contact: Contact: </p><p>Schedule of Equipment/Software or Services Attachments Address of Installation: </p><p>Description of Equipment to be Financed: Value of Equipment to be Financed: </p><p>(Optional) Attach files containing equipment/software or services to be financed (word, excel, PDF, etc.) Depending on the size of the uploads (10mb max), it might take several minutes to submit your application: </p><p>Proposed Finance Terms</p><p>Number of Months Financing type: (Installment Loan or Lease): Installment Loan If leasing, Lease Purchase Option $1 or FMV: Lease</p><p>Please select a financing type </p><p>* Complete financial statements may be required for all transactions exceeding $100,000. </p><p>I hereby represent all information is true, correct and complete. By placing my/our full name and date of birth in the indicated boxes I/ we affirm my/our signature to be acceptable as a written signature. I/we authorize the release of any credit information, business or personal to be released to the submitter, its assigns or the above named vendor. Submitter complies with section 326 of the US Patriot Act. This law mandates that submitter or its assigns request and verifies certain information about you and your company. A copy or fax of this authorization shall be valid as the original. Electronic Signature #1: Date of Birth: Title: Date: * * (Type Authorizing Officer Name) (MM/DD/YYYY) (MM/DD/YYYY) If two Officers/Partners/Owners are listed, a second electronic signature is required Electronic Signature #2: Date of Birth: Title: Date:</p><p>(Type Authorizing Officer Name) (MM/DD/YYYY) (MM/DD/YYYY)</p><p>Have a question? Please call US JLuxFunding, LLC at or e-mail </p>