* Denotes required field
Company Name:
DBA Name (if applicable):
Type of Business: - Select One - Sole Proprietor Partnership LLC Corporation Non-Profit
Federal Tax ID:
Time in Business:
Business Address:
City:
State:- Select State -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
ZIP:
Phone:
Website URL:
Your Sales Rep: -- I do not have a sales rep --
Location:
Cost:
Description:
First Name:
Last Name:
Email:
SSN #: SSN Collected Edit Value
Job Title:
Ownership (%):
Address:
State: - Select State -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zipcode:
This application submitted electronically shall have the same force and effect as if the application bore an inked original signature(s). The above information, together with any accompanying financial statements, schedules, or other materials, is submitted for the purpose of obtaining credit and is warranted to be true, correct and complete. The undersigned hereby warrants that any individual identified above who is either a principal, a personal guarantor or a sole proprietor of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, has provided his/her written authorization for inquiry into their credit worthiness, including but not limited to obtaining a consumer credit report, and shall hold Vista Capital Corporation and its assignees, agents or nominees harmless from same. You understand that such investigation may include seeking information as to the background, credit and financial responsibility of your officers and principals (or any of them). 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 or age (provided the applicant has the capacity to enter into the 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. If for any reason your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please write to Vista Capital Corporation, 3030 N. Central Ave., Suite 402, Phoenix, AZ 85012.
