Name of Business : Type : Please Select Sole P Partnership Corp Business Phone : Fax : Email Address : Address : City : State : Zip : Country : Years in Business : Federal ID : Dun & Brad : Owner name : Social Security : Home owner or renter : Please Select Owner Renter Number of years at current address : Home Address : Home Phone : Cell : Pager : Nearest Relative(required) : Relation : Phone : Primary bank name : Account : Contact Name : Phone : Non-creditcard Business reference : Account : Contact Name : Phone : Employer (if employed outside of vending) : Position : Salary : Phone : Payment Reference : Please Select Authomatic Withdraw Pay by Check/Billing Statement Important please read before submitting I understand that Wittern Financial Services is relaying on this information in extending credit card and i warrant it to be true. I hereby authorize Wittern Financial Services or and bank/ and or trade bureau or other investigative agencies employed by Wittern Financial Servieces to investigate the references herein listed or other data obtained from me or any other person pertaining to my credit and financial responsibility. The undersigned authorizes all parties contacted to release credit information requested its successor or assigns.