D&B
<mark>Decide with Confidence</mark>

# D&B Business Information Form

Welcome to D&B. The information you provide will be used as a basis for credit.

insurance, marketing and other business decisions. A D&B business analyst may contact

you upon receipt of this completed form to clarify some of the information.

# D&B Business Information Form (cont.)

## 1 - GENERAL INFORMATION

Business Name <empty>
DBA <empty>
Date the Business started: <empty>
Street Address <empty>
City, State <empty>
Zip Code <empty>
Number of full & part-time employees, including owners <empty>
Mailing Address <empty>

Names of Owners/Officers: <empty>

1. <empty>
Title: <empty>
Work Phone: <empty>

2. <empty>
Title: <empty>
Fax: <empty>

3. <empty>
Title: <empty>
<empty>

2 - OPERATIONS - A DESCRIPTION OF THE BUSINESS FUNCTION

# D&B Business Information Form (cont.)

## Describe what the business does:

Do you offer your product or service on CASH or CREDIT: <empty>
If you offer credit - please specify billing terms: <empty>
Sales territory is:
LOCAL
NATIONAL
REGIONAL
INTERNAT'L
The customers of this business are primarily:
THE GENERAL PUBLIC
COMMERCIAL ACCOUNTS
OTHER <empty>

# D&B Business Information Form (cont.)

## 3 - HISTORY OF THE BUSINESS - HOW THE BUSINESS GOT STARTED

The legal structure is:

Proprietorship
Partnership
Corporation
Other <empty>

If trade style is registered:

City/Town
Registered <empty>
Date registered <empty>

Is trade style registered? YES
NO

This money came from:
Loans from the owners
$<empty>
Savings $<empty>
*Other $<empty>
*Please
specify:<empty>

The dollar amount used to start this business was
$<empty>

Date incorporated <empty>
State where incorporated <empty>

4 - FINANCE - A LISTING OF THE BUSINESS ASSETS AND LIABILITIES
If this information has been prepared by your accountant, please attach a copy of the financial statement to this form.
Date of the figures below: <empty>/<empty>/<empty>
The month the fiscal year ends: <empty>

# D&B Business Information Form (cont.)

## 3 - HISTORY OF THE BUSINESS - HOW THE BUSINESS GOT STARTED (cont.)

Date / Month: ___________________

Financial snapshot (fill-in $ / dates)
- Inventory $ ________
- Net Fixtures/Equip. $ ________
- Accounts receivable $ ________
- Cash in Bank $ ________
- Other Assets $ ________
- Bank Loans $ ________
- Accts Payable $ ________
- Notes to Owners $ ________
- Other Liabilities $ ________
- Monthly Rent $ ________
- Fire Ins. on Fixtures $ ________
- Equipment $ ________
- Sales for the period: From __/__/__ to __/__/__ — Sales were $ ________
- Profits for the period: From __/__/__ to __/__/__ — Profits were $ ________

Section 5 — Background information on the owner(s) / officers
(For owners outlined in section 1; up to 3 owners shown. Attach resumes if >3.)

Owner #1
- Title: ___________________
- Year of Birth: ___________
- College: _________________
- Degree Received: _________
- Date Rec'd: __/__/____
- % Stock Ownership: _______

Owner #2
- Title: ___________________
- Year of Birth: ___________
- College: _________________
- Degree Received: _________
- Date Rec'd: __/__/____
- % Stock Ownership: _______

Owner #3
- Title: ___________________
- Year of Birth: ___________
- College: _________________
- Degree Received: _________
- Date Rec'd: __/__/____
- % Stock Ownership: _______

Previous work experience (for each owner from age 21 or back 25 years OR attach resume)
Table columns:
- Name (Owner #)
- Positions Held
- Yr Started
- Yr Ended
- Company Name
- City
- State

(Multiple blank rows provided for each owner to list employment entries.)

# D&B Business Information Form (cont.)

## 3 - HISTORY OF THE BUSINESS - HOW THE BUSINESS GOT STARTED (cont.)

List other current and/or previous businesses owned for each owner:
Owner #1: <empty>
Owner #2 <empty>
Owner #3 <empty>

<table><tr><th>Bank Names</th><th>City</th><th>State</th><th>Phone Number</th><th>Account
Number</th><th>Contact Person</th></tr><tr><td>1.</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>2.</td><td></td><td></td><td></td><td></td><td></td></tr></table>

Signature: <empty>
Date: <empty>