Manufacturer Application

Manufacturer Name*

DBA*

Tax ID*

Street address*

City*

State/Region*

Postal Code*

Phone*

Fax Number

Email*

Website URL*

State Of Incorporation*

Date of Incorporation*

Legal Structure*

Has the company had any adverse findings regarding corporate practices by any regulatory agency within the past 5 years?*

If yes, please explain

Are there any current or pending claims, lawsuits, or judgements against the company?*

If yes, please explain

Has the company ever been suspended or terminated from doing business with any lending institution?*

If yes, please explain

Attached Copy of Business License

Business References

Please List Banking Relationship, Financial Company, Floor Plan, ETC.

Reference 1*

Name, Address, Phone, & Contact Required

Reference 2*

Name, Address, Phone, & Contact Required

Reference 3

Name, Address, Phone, & Contact Required

Reference 4

Name, Address, Phone, & Contact Required

Funding Information

Account Information For Funding Loan Contracts

Name of Bank*

Name on Account*

Routing Number

Account Number

For Principals

Principal Name*

% Of Ownership*

Residence Address*

Title*

Contact Number*

Date of Birth*

Name

% Of Ownership

Residence Address

Title

Contact Number

Date of Birth

Name

% Of Ownership

Residence Address

Title

Contact Number

Date of Birth

It is understood that Mobility will make reference inquiries and may order credit reports and/or independent background checks on the dealer/manufacturer, dealership and/or principals. By submitting this completed packet, the dealer authorizes the release of financial and other information as may be required to evaluate the dealer and/or dealership.

Principal 1 *

Print full name

Date*

of signature

Principal 2

Print full name

Date

of signature

Principal 3

Print full name

Date

of signature