Vendor Questionnaire

COMPANY INFORMATION

OWNER INFORMATION

Include all parties with at least 25% ownership.

OWNER ONE
OWNER TWO
OWNER THREE
OWNER FOUR

SALES & FINANCE CONTACTS

SALES CONTACT
FINANCE CONTACT

CORPORATE INFORMATION

OFFICERS, DIRECTORS, MEMBERS OR PARTNERS

INSURANCE INFORMATION

FORECASTED BUSINESS

SECURITY POLICY

In lieu of the questions below, you may attach a copy of your existing policy. Please indicate how you protect customer Non-Public Information when communicating with LaVictoire, or once in receipt of Customer Information.

IN TRANSIT
AT REST
AT TIME OF DISPOSAL

I am submitting this Vendor Questionnaire on behalf of the business named herein. I certify that I made no misrepresentation in this Vendor Questionnaire or in any related documents, that all information is true and complete, that I did not omit any important information, and that I am obligated to amend and/or supplement the information provided in this Questionnaire if any of the material facts represented herein should change. Lender is authorized to verify with other parties and to make any investigation of our Business, either directly or through any agency employed by the Lender for that purpose. I understand that Lender will retain this Questionnaire and any other information Lender receives, even if a mutual Agreement is not obtained.

The transmission of this application as an “electronic record” containing my “electronic signature,” as those terms are defined in applicable federal and/or state laws, shall be as effective, enforceable and valid as if a paper version of this application were delivered containing my original written signature.

AUTHORIZED REPRESENTATIVE