DEALER INFORMATION
Dealer
Address
Phone
Fax
Email
Date
EQUIPMENT DESCRIPTION
Itemize Maintenance, Services, Training, Installation, if applicable
Qty
 Manufacturer
Model Number
Description
New Used
Equipment Cost
New Used
New Used
New Used
Total Equipment Cost
TERM/LEASE PAYMENT SCHEDULE
Term (Months)
24 36
48 60
Security Deposit/Advance Payment (Check only one)
Security Deposit(s) Advance Payment(s)
Lease End Purchase Option
FMV 10%
$1.00 Loan
CUSTOMER INFORMATION
Lessee Name
Lessee Phone Number
Lessee Email
Address
City
County
State
Zip
Signer Name & Title
TAX ID Number
Nature of Business
Year
Started
Type of Business
Corporation Partnership Sole Proprietor PC L.L.C.
Phone
Fax
REFERENCES
Bank References
Account #
Bank Phone #
Bank Contact
Trade References
Account #
Trade Phone #
Trade Contact
PERSONAL INFORMATION ON PARTNERS, PROPRIETORS, OR GUARANTORS
Name
Name
Title
Social Security #
Title
Social Security #
Address
City
St
Zip
Address
 City
St
Zip
Phone #
Phone #
AUTHORIZATION
The undersigned individual(s) who is either a Principal, Sole Proprietor, or Personal Guarantor of the Credit Applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the Applicant or in the evaluation of his or her personally guaranty, if applicable, hereby consents to and authorized the use of a consumer credit report on the undersigned individual(s) by the above names business credit grantor and/or its assigns, from time to time as may be needed, in the initial credit evaluation and subsequent review processes. I/we stand advised that the Advance Payment or Security Deposit is not refundable unless this application is rejected by Lessor.

Partner, Proprietor, Guarantors
X

Partner, Proprietor, Guarantors
X
NOTICE

If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please call 800-666-6811 within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement. NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with the law concerning the creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, D.C. 20590.