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LESSEE
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Legal Name
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Contact
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Phone No.
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Trade Name (if applicable)
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Fax No.
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Business Street Address/City/State/Zip Code
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E-Mail Address
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Type of Business D & B #
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Years In Business
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Tax Identification No.
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Proprietorship
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Corporation (State ___________)
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General Partnership
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Limited Partnership
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Limited Liability Company
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State or Local Government
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PRINCIPALS
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Name & Address
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Title
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Social Security No.
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US Citizen?Yes No
Date of Birth _____/_____/_____ |
Home Phone No.
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(Owners, partners and principal officers)
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Name & Address
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Title
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Social Security No.
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US Citizen? Yes No
Date of Birth ____/______/_____ |
Home Phone No.
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PATRIOT ACT
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To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. We will need a copy of your driver's license or other identifying documents when signing the lease contract.
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E-mail Address
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EQUIPMENT
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Equipment Location ( check if same as Lessee's address)
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Credit Requested$
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Quantity
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Make and Model
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General Description ( check if equipment is used)
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KEY TERMS
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Lease Term (months)
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Purchase Option Price: Fair Market Value Estimated Fair Market Value of _______% of the total Equipment Cost
Nominal Price of $_______ Nominal Price of _______% of the total Equipment Cost
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REFERENCES
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Bank *
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Account No.
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Contact
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Phone No.
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Trade Creditor **
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Account No.
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Contact
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Phone No.
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Secured Debt or Lease Creditor
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Account No.
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Contact
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Phone No.
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Secured Debt or Lease Creditor
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Account No.
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Contact
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Phone No.
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Each individual signing below certifies that the information provided in this credit application is accurate and complete. Each individual signing below authorizes you or any lender or funding source which may be utilized (collectively referred to as "Lenders") to obtain information from the references listed above and obtain a consumer credit report that will be ongoing and relate not only to the evaluation and/or extension of the business credit requested, but also for purposes of reviewing the account, increasing the credit line on the account (if applicable), taking collection action on the account, and for any other legitimate purpose associated with the account as may be needed from time to time. Each individual signing below further waives any right or claim which such individual would otherwise have under the Fair Credit Reporting Act in the absence of this continuing consent. |
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X
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Signature |
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Signer's Printed Name |
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Date |
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X
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Signature |
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Signer's Printed Name |
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Date |
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