Application
Fax this application to us at 316-794-2110 or mail it to us at;
B.E.L.T., Inc.
P.O. Box 12526
Wichita, KS 67277
Business Information:
Company Name:
 Telephone:
Proprietor/DBA:
 Fax:
Business Address:
 Contact:
Type of Business:
 Number of Employees:
E-Mail
Years in Business:
 Years at this Address:
 Fed ID #:
 State Incorporated:
Insurance Company:
 Agent:
 Telephone:
Equipment Information:
Equipment Description:
 Cost:
Equipment Location:
 County:
Equipment Dealer:
 Phone:
 Contact:
 Tax Exempt:
Trade References:
Name:
 Phone:
 Contact:
 Account #:
Name:
 Phone:
 Contact:
 Account #:
Name:
 Phone:
 Contact:
 Account #:
Bank References:
Name:
 Phone:
 Contact:
 Account #:
Name:
 Phone:
 Contact:
 Account #:
Ownership:
Name:
 Title:
 Soc. Sec. #:
Address:
 Ownership Interest:
 Spouse:
Name:
 Title:
 Soc. Sec. #:
Address:
 Ownership Interest:
 Spouse:
Other Information:
The undersigned authorizes B.E.L.T., Inc. or its designee to investigate our credit/financial history and all parties contacted to release any information requested by telephone, facsimile or any other means. We will provide financial statements if deemed necessary. Everything that has been stated in this application is correct and true.


Date:  _________________________      Authorized:  _________________________