Company Name ________________________________ D/B/A ______________________________________

Address ______________________________City _______________________ State ______ Zip __________

Phone ________________________ Fax _______________________ Cell Phone _______________________

Contact _______________________ Business Started __________ Fed ID # __________________________

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EQUIPMENT & STRUCTURE OF THE TRANSACTION

Equipment Description ______________________________________________________________________

Additional Collateral  ________________________________________________________________________

Vendor __________________________ Phone ___________________________ Contact ________________

Equipment Cost $_________________  Down Payment $_______________ Balance $__________________

Purchase Option _______  Seasonal Payments ________  # of Seasons _________ Straight Pay________

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PRINCIPALS AND GUARANTORS

Name _____________________ SS # ________________ Spouse _______________ SS # ________________

Address _________________________  City _______________________  State ________ Zip ____________

Have any of the principals or Guarantors filed for bankruptcy?   NO_____________   Yes _____________

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CREDIT REFERENCES

Bank ________________________ Acct # ___________________ PH # _____________________

Bank ________________________ Acct # ___________________ PH # _____________________

Finance Co. ___________________ Acct # ___________________ PH # _____________________

Supplier _______________________________________________ PH # ____________________

Supplier _______________________________________________ PH # ____________________

Email: Info@prairiefinancialinc.com

Phone: 816-554-3863

Fax:816-554-3875