Vendor Information

Vendor Name:		Estimated Equipment Cost:
Vendor Contact:		Brief Equipment Description:
Vendor Phone:	Vendor Fax:

Customer Information

Full Legal Company Name	Billing Address		Business Street Address (if different from Billing Add.)
Bank Use:	City, State, Zip		Phone:
Type of Business	Years In Business	Annual Sales	Email Address
Business Owner’s Name	Title	Years As Owner	# of Employees	Date of Birth
Legal Structure: (circle one) LLC Non-Profit Sole Proprietor Partnership Corporation	State of Incorporation		Tax ID Number
Principal I Name	Principal I Address		City, State, Zip
Principal I E-Mail Address	Principal I Social Security Number		Principal I Ownership %
Principal II Name	Principal II Address		City, State, Zip
Principal II E-Mail Address	Principal II Social Security Number		Principal II Ownership %

Bank & Trade References

Bank	Phone #	Account #	Contact
Bank	Phone #	Account #	Contact
Company Name	Phone #	Account #	Contact
Company Name	Phone #	Account #	Contact

Your Signature

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 Direct Capital Corporation 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 Direct Capital Corp. regarding our account. Information should be sent to the fax and/or email address given for the account.

______________________________________________________ _____________________________________________________

Principal I Signature Date Principal II Signature Date

Please Fax to FitnessScape, at 1-615-890-2276.

DIRECT CAPITAL CORPORATION ¨ 155 COMMERCE WAY ¨ PORTSMOUTH, NH 03801

Phone: 1-800-749-5895