Performance Capital

Referral Partner Profile

Simply fill out the Referral Partner Profile below and let Performance Capital approve your next deal!

Company Information

Company Name
Contact
Contact Title
Street Address
City
State
Zip

DBA
Fed ID#
Telephone
Fax
Email
Website

Business Information

Years in Business
Years under current ownership
Type of Business

Bank Reference

Bank Name
Account Number
Bank Telephone
Bank Contact
Date Account Opened

Principal Owner Information

Principal 1
Social Security #
Address	</TEXTAREA;?> </td> </tr> <TR vAlign=top;?> <TD width="51%" class=style18;?>Ownership %</td> <TD width="49%" ;?><INPUT size=30 name=principal1_ownership;?> </td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> <TD width="50%" vAlign=top;?><TABLE width="100%" border=0;?> <tbody> <tr> <TD vAlign=top width="99%"><TABLE cellSpacing=1 width="99%" border=0;?> <tbody> <tr> <TD width="53%" vAlign=top class=style18;?>Principal 2</td> <TD width="47%" ;?><INPUT id=Principal2 size=30 name=principal2_name;?> </td> </tr> <tr> <TD vAlign=top class=style18;?>Social Security #</td> <td><INPUT size=30 name=principal2_ssn;?> </td> </tr> <tr> <TD vAlign=top class=style18;?>Address</td> <td><TEXTAREA name=principal2_addr cols=24;?></TEXTAREA;?> </td> </tr> <tr> <TD width="53%" vAlign=top class=style18;?>Ownership %</td> <TD width="47%" ;?><INPUT size=30 name=principal2_ownership;?> </td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table> <P class=style19 style15;?>Other Funding Source References</p> <TABLE cellSpacing=2 cellPadding=2 width="99%" border=0;?> <tbody> <tr> <TD width="50%" vAlign=top;?><TABLE cellSpacing=1 width="100%" border=0;?> <tbody> <tr> <TD width="49%" class=style18;?>Funding Source #1</td> <TD width="51%" ;?><INPUT size=30 name=fund_source1;?> </td> </tr> <tr> <TD width="49%" class=style18;?>Source Telephone </td> <TD width="51%" ;?><INPUT size=30 name=fund_telephone1;?> </td> </tr> <tr> <TD width="49%" class=style18;?>Source Contact </td> <TD width="51%" ;?><INPUT size=30 name=fund_contact1;?> </td> </tr> <tr> <TD width="49%" class=style18;?>Funding Source #2</td> <TD width="51%" ;?><INPUT size=30 name=fund_source2;?> </td> </tr> <tr> <TD width="49%" class=style18;?>Source Telephone </td> <TD width="51%" ;?><INPUT size=30 name=fund_telephone2;?> </td> </tr> <tr> <TD width="49%" class=style18;?>Source Contact </td> <TD width="51%" ;?><INPUT size=30 name=fund_contact2;?> </td> </tr> </tbody> </table></td> </tr> </tbody> </table> <P class="style18">By typing in your name, dating, and clicking the "Submit" button or by undersigning and faxing (954-523-0766) you are stating that you are the principal of the above company and provides instruction to Performance Capital Corporation (and any assignee or potential assignee thereof) authorizing review of his/her personal credit profile from a national credit bureau and authorizes all requested bank and trade information to be released via telephone or fax. The undersigned hereby waives any privacy or credit information rights or regulations. </p> <P class="style14">Signature <INPUT size=30 name=signature_name;?> Date <INPUT size=30 name=signature_date;?> </p> <P ;?> <span class="style14"> <INPUT type=submit value=Submit name=Submit_Button_refer_to_Signature_Statement;?> <INPUT type=reset value=Reset name=B2;?> </span> </p> </FORM;?></td> <!-- SPACER --> </tr> </table></td> </tr> </table> </html;?>