Confidential Dealer Application

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Dealership Information

Company Legal Name:*

DBA if applicable

Physical Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax*

Own or Rent*

Years in Business*

Years at current location*

Type of Business*

Is the business incorporated? If so, what is its tax ID number (EIN number)*

Amount Requested

Officer/Owner Information

Officer/Owner Social Security#*

Officer/Owner Date of Birth*

Officer/Owner Cell Phone #

Officer/Owner Drivers License #*

Officer/Owner Name*

First Last

Officer/Owner Email Address*

Enter Email Confirm Email

Officer/Owner Title:

Officer/Owner Home Address*

Street Address Address Line 2 City State ZIP Code

Officer/Owner Years At Current Location*

Check one*

Lease

Own

Officer/Owner Certification

I hereby certify the information contained within this application and on any accompanying financial statements in true, complete and accurate. I authorize Auto Bank Floorplan to obtain credit information from a credit bureau and any financial institution trade creditor that I have provided as well as any other credit investigation that Auto Bank Floorplan deems necessary. I authorize Auto Bank Floorplan to contact any third persons and to disclose information, including information contained in this application for the purpose of among other things, obtaining inter creditor agreements and protecting Auto Bank Floorplan security interest.

Officer/Owner Digital Signature

The digital signature field will only work on some computers and tablet devices. If this field does not work for you. AutoBank will request a signature at a later date.

Partner/Co-Owner Information

Partner/Co-Owner Social Security#

Partner/Co-Owner Date of Birth

Partner/Co-Owner Drivers License #

Partner/Co-Owner Cell Phone #

Home Phone #

Partner/Co-Owner Name

First Last

Partner/Co-Owner Email Address

Enter Email Confirm Email

Partner/Co-Owner Title:

Partner/Co-Owner Home Address

Street Address Address Line 2 City State ZIP Code

Partner/Co-Owner Years At Current Location

% of Ownership

Check one*

Lease

Own

Do any of the owners have any on-going lawsuits they are defending or any judgements?

If yes, please provide explanation:

How did you discover Auto Bank Floor Plan?

Auction References:

Phone #:

Year Registered:

Auction References:

Phone #:

Year Registered:

Other Floor Plan:

Auction Access #:

Dealer License #:

Partner/Co-Owner Certification

Partner/Co-Owner Digital Signature

The digital signature field will only work on some computers and tablet devices. If this field does not work for you. AutoBank will request a signature at a later date.

This field is for validation purposes and should be left unchanged.