application

CORPORATE INFORMATION

Company

DBA Name

Street

City

State

Zipcode

Email

Phone Number

Contact Name

Cell Phone Number

Company Type

Date Established

Type of Business

Federal Tax ID#

VENDOR INFORMATION

Please complete as much as possible. If some of the info is unknown, you may leave it blank.

Equipment Supplier

Street

City

State

Zipcode

Phone Number

Sales Rep

EQUIPMENT INFORMATION

Equipment Cost

(Excluding Sales Tax)

Lease Term

Purchase Option

$1.00 FMV Prepaid

Equipment Description

BUSINESS OWNER INFORMATION

Name

Title

Street

City

State

Zipcode

Social Security Number

Home Phone

% Owned

More Than One Owner?

Yes No

BUSINESS OWNER 2 INFORMATION

Name

Title

Street

City

State

Zipcode

Social Security Number

Home Phone

% Owned

Comments

AUTHORIZATION TO RELEASE INFORMATION:

Each individual certifies that the provided information in this credit application is accurate and complete. Each individual applying authorizes you and your designees 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 the purposes of reviewing the account, increasing the credit line on the account (if applicable), taking collection action on the account, and any other legitimate purpose associated with the account as may be needed from time to time. Each individual applying further waives any right or claim that such individual would otherwise have under the Fair Credit Reporting Act in the absence of this continuing consent.