Customer Application Form

Full Legal Business Name:  
DBA Name:   (if any)
Fed Tax ID:   (no dashes or spaces) 
Phone Number:   - -
Business Type:  
Year Business Started:  
Current Ownership Date:   (mm/dd/yyyy)
Contact:  

Corporate Address
Address:  
City:  
State:  
ZIP Code:  

Billing Address
Address:  
City:  
State:  
ZIP Code:  

Principal #1
Full Legal Name:  
Title:  
% Ownership:  
Social Security Number:   - -
Street Address:  
City:  
State:  
ZIP Code:  

Principal #2
Full Legal Name:  
Title:  
% Ownership:  
Social Security Number:   - -
Street Address:  
City:  
State:  
ZIP Code:  

Principal #3
Full Legal Name:  
Title:  
% Ownership:  
Social Security Number:   - -
Street Address:  
City:  
State:  
ZIP Code:  

Equipment Description
Manufacturer:  
Model Number:  
Quantity:   (Main Units)
Accessories:  
List Price:$
Purchase Price:$
New/Used:  
Used Age:    (months)

Lease Information
Lease Term:    (months)
Payment Frequency:  
End of Term Option:  
Special Request:  

References
Bank #1 Name:  
  Address:  
  City:  
  State:  
  ZIP Code:  
  Account Type:  
  Account Number:  
  Contact Name:  
  Phone Number:   - -

Bank #2 Name:  
  Address:  
  City:  
  State:  
  ZIP Code:  
  Account Type:  
  Account Number:  
  Contact Name:  
  Phone Number:   - -

Trade #1 Name:  
  Address:  
  City:  
  State:  
  ZIP Code:  
  Account Number:  
  Contact Name:  
  Phone Number:   - -

Trade #2 Name:  
  Address:  
  City:  
  State:  
  ZIP Code:  
  Account Number:  
  Contact Name:  
  Phone Number:   - -

Trade #3 Name:  
  Address:  
  City:  
  State:  
  ZIP Code:  
  Account Number:  
  Contact Name:  
  Phone Number:   - -

Supplier Information
Vendor #1 Name:  
  Address:  
  City:  
  State:  
  ZIP Code:  
  Quote Number:  
  Contact Name:  
  Phone Number:   - -

Vendor #2 Name:  
  Address:  
  City:  
  State:  
  ZIP Code:  
  Quote Number:  
  Contact Name:  
  Phone Number:   - -

 

Comments:  
Additional Information Being Sent:  
Yes No


PLEASE READ AND IF AGREED INPUT YOUR NAME BELOW

You agree that by providing the information, you are, on behalf of yourself, the principals and the company, authorizing the leasing company or its agents to : (i) pull credit reports and investigate its financial responsibility and credit worthiness; and (ii) to update the customer's credit profile from time to time in the future at the leasing company's sole discretion.

Acknowledgement and Authorization:  
(Form will not be processed without Acknowledgement and Authorization)