Online Application

Company Information

Please complete all fields with an asterisk (*).

* Company Name:

RSA Representitive: Bill W. Chuck O. Darrell J. Mark M. Roger S. Ryan M. Shawn M. Steve S. Terry G.

Street Address:

City:

State:

Zip:

* Business Phone:

Business Fax:

* Contact Name:

Contact Email:

Gross Annual Revenue:

Estimated Time in Business (Years and Months):

Ownership Information

Please provide for person(s) with 20% or more ownership.

* First Officer Name:

Title:

Social Security #:

Ownership:

Email Address:

Second Officer Name:

Title:

Social Security #:

Ownership:

Email Address:

Authorization

I hereby authorize the release of business and/or personal credit information to Taycor Financial, its affiliates, partners, or assignees (1) from any source including credit bureau reporting agencies and my bank for the purpose of extending credit, (2) and to any credit reporting agency.

Additionally I hereby authorize the release of my application without notice, to any other non-related potential lending sources for consideration of approval of credit. I hereby represent all information is true, correct and complete.

A photo static and/or facsimile copy of this authorization shall be valid as the original. Submission of this form is consent that information transmitted via the Internet carries with it inherent risk when done via an unsecured network connection. Signature below must be done by only an authorized member and must be 18 years of age or older.

* Authorized Signer:

* Title:

Second Authorized Signer:

Second Signer's Title:

Please complete all fields with an asterisk (*).