1.    Legal Name & Phone Number________________________________    (____)___________

2.    Trade Name:___________________________________________________________________

3.    Street Address:_________________________________________________________________

4.    City:_____________________    County:____________  State:_________ Zip:______________

5.    Federal Taxpayer ID Number: _________________

6.    President, Sole Proprietor, or Senior Partner: Name: _______________________% Owned:____

      Home Address: ________________________City, State, Zip_____________________________

      Home Phone #: (___)____________Social Security #:______________Date of Birth:_________

7.    Secretary or Other Partner: Name: _____________________________________% Owned:_____

      Home Address: ________________________City, State, Zip_____________________________

      Home Phone #: (___)____________Social Security #:______________Date of Birth:_________   

8.    Other Officer, Shareholder, or Partner: Name: ____________________________% Owned:____

      Home Address: ________________________City, State, Zip_____________________________

      Home Phone #: (___)____________Social Security #:______________Date of Birth:_________

9.    Name of Accountant: ___________________Firm :_________________Phone(___)__________

      Street Address____________________City:_______________State_____Zip:_______________

10.  Name of Attorney: _____________________Firm: _________________Phone(___)__________

      Street Address____________________City:_______________State_____Zip:_______________

11.  Name of Bank: __________________Bank officer: ____________________Phone(___)_______

      Account # _________Street Address_______________City:____________State_____Zip:_____

12.  Do you have any Federal or State Taxes past due? Yes____  No____
      If yes has lien been filed? Yes_____ No_____ If yes please list type & amounts ______________
_________________________________________________________________________________

13.  If leasing space Name and phone # of Landlord________________________________________