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Owner# 1/Principal Information

Owner# 2/Principal Information

Reference# 1

Reference# 2

Reference# 3

By signing below, the Merchant and its Owners / Principals: (1) certify that all information and documents submitted in connection with this application is true, correct and complete; (2) authorize The Belmont Franklin Group its agents, partners, and lenders, to receive credit reports and any other information regarding the Merchant and its Owners and Principals from third parties, to verify any information provided on the application; (3) to receive an occasional promotion or offer by email or fax.