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CREDIT & LEASE APPLICATION
Representative:  
Date:  
Business
Business Name/Lessee Phone:
Address Fax:
City
 State:  Zip:
D&B
Location of Equipment if other than above, time in business at each additional location.
Corp  Part  Prop  LLC 
Type of Business  Age of Business Number of Employees  Federal Tax Number
Name of Corporate Secretary Install Date Date of Incorporation State of Incorporation
Comments
Ownership
Principal or Officer (1)
Spouse
Title
% Owned
Social Security Number
Home Address
City
State
Zip
Home Phone
Principal or Officer (2)
Spouse
Title
% Owned
Social Security Number
Home Address
City
State
Zip
Home Phone
Banks
Bank/Branch
Date Opened
Account Number
Loan Number
Phone
Contact Officer
Trades
Trade References
Date Opened
High Credit
City, State
Account
Phone
Contact
Vendor
Vendor Name
Phone Number
Fax Number
Address
City
State
Zip
Home Phone
Equipment to be leased
Condition report may be required
New Used
Equipment Cost
% Tax
Tax Amount
Rate Factor
Term
Advance Payments
Total Cost
I hereby certify: (i) the information provided above is true and correct, (ii) you are hereby authorized to investigate all bank, credit and trade references, and said references are hereby authorized to release any requested information to you or your nominee, (iii) such authorization shall extend to obtaining personal credit profile in considering this application and subsequently for the purposes of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account, (iv) this information may be transmitted by us to you and by you to underwriter/s for the purpose of granting to me credit, either electronically or manually, and that by submitting this application, I take full responsibility for transmission thereof, (v) I am over 18 years of age, (vi) I acknowledge my rights under the Fair Credit Opportunity Act, and (vii) this request is for business and not consumer purposes.
Signed: Title: Date:
Signed: Title: Date:
Signed: Title: Date: