Filler'up Group, Inc

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GAS STATION FINANCING APPLICATION

Company Legal Name:

Email:

Street Address:

County:

City/State/Zip

Federal Tax I.D. #:

Transaction Description:

Real Estate:	Acquisition	Refinance	Remodel New Site Development
Term (Real Estate Transactions Only)	10 Years	15 Years	20 Years
Term:	5 Years	7 Years

Borrower Information:

Dealer

Number of sites leased/operated

Number of sites owned

Distributor

Number of sites supplied

Number of sites owned/operated

Experience

years

Brand(s)

Purchase Price:

Finance Amount:

Information on Site(s) to be financed:

1. Full Address Property #1

Station age:

years

Operated Since (year):

2. Full Address Property #2

Station age:

years

Operated Since (year):

Business Phone:

Fax:

Home Phone:

Cell Phone:

Please Check:

Corporation S Corp LLC Partnership Proprietorship

Year Incorporated: State Incorporated: Year Started:

Owner / Principal Information

Full Name:

Home Address:

City/State/Zip:

Phone Number:

Social Security #:

US Citizen OR Legal Resident (Please Provide Validation)

Percent (%) of Ownership

Full Name:

Home Address:

City/State/Zip:

Phone Number:

Social Security #:

US Citizen OR Legal Resident (Please Provide Validation)

Percent (%) of Ownership

Bank Information

Name of Primary Bank:

Bank Contact Name:

Account Number:

Bank Contact Phone Number:

Name of Secondary Bank Reference:

Bank Contact Name:

Account Number:

Bank Contact Phone Number:

Oil Company Information

Brand:

Supplier:

Gallons/Month (Total):

Supplier Contact Name:

Supplier Phone Number:

Additional Profit Center Information

Inside Sales/Month:

Car Wash Sales/Month:

QSR:

Other Sales/Month:

PLEASE READ THIS SECTION I hereby authorize you to disclose the personal and/or business credit information set forth in this application. I hereby represent to Filler'up Group Inc., that such information is true, correct and complete. A photostatic copy of this authorization shall be valid as the original. You irrevocably authorize us to execute and file any UCC financing statement in your name which relates to the Note and Security Agreement. You agree to give Filler'up Group, Inc. any financial information upon our request. If your application for business credit is denied, you have the right to a written statement of specific reasons for denial. To obtain the statement, please contact us within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement. You agree that all information and materials submitted by you or on your behalf in support of this application shall become the property of Filler'up Group, Inc. Notice: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit protection Act. The federal agency that administers compliance with the law concerning the creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580. The undersigned agrees that Filler'up Group, Inc. has the right to confirm the accuracy of the above referenced credit information and that Filler'up Group, Inc. has the right to accept or reject this application.