Leasing Application  
SUPPLIER INFORMATION
VENDOR NUMBER
VENDOR NAME
CONTACT
PHONE (xxx-xxx-xxxx)
CUSTOMER INFORMATION
LEGAL COMPANY NAME
ADDRESS
CITY
STATE
ZIP
PHONE
(format: xxx-xxx-xxxx)
FED. TAX I.D. #
(format: xx-xxxxxxx)
CONTACT PERSON
E-MAIL ADDRESS
TYPE OF BUSINESS
Corporation   Proprietorship   Partnership
STATE OF INCORPORATION
# OF YEARS IN BUSINESS UNDER CURRENT OWNERSHIP
# OF EMPLOYEES
DESCRIPTION OF BUSINESS
BILLING ADDRESS (IF DIFFERENT FROM ABOVE)
CITY
STATE
ZIP
LEASE INFORMATION
DESCRIPTION OF PRODUCT
PAYMENT AMOUNT
PRODUCT COST
LEASE TERM
PURCHASE OPTION
FMV 10% $1.00
PERSONAL DATA
NAME
HOME ADDRESS
CITY
STATE
ZIP
SOCIAL SECURITY #
(format: xxx-xx-xxxx)
TITLE
% OWNERSHIP
REFERENCE DATA
LIST PRESENT BANK(S) - PREVIOUS BANK IS REQUIRED IF APPLICANT HAS BEEN AT PRESENT BANK LESS THAN TWO YEARS
PRESENT BANK OF APPLICANT
BRANCH
PHONE
(format: xxx-xxx-xxxx)
NAME OF BANK OFFICER
ACCT. #
PREVIOUS OR SECOND BANK OF APPLICANT
BRANCH
PHONE
(format: xxx-xxx-xxxx)
NAME OF BANK OFFICER
ACCT. #
TRADE REFERENCE 1 NAME AND ADDRESS
PHONE
(format: xxx-xxx-xxxx)
CONTACT
TRADE REFERENCE 2 NAME AND ADDRESS
PHONE
(format: xxx-xxx-xxxx)
CONTACT
TRADE REFERENCE 3 NAME AND ADDRESS
PHONE
(format: xxx-xxx-xxxx)
CONTACT

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 assignee 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.

X  
OWNER #1 - SIGNATURE SIGNER’S PRINTED NAME DATE
 
X  
OWNER #2 - SIGNATURE SIGNER’S PRINTED NAME DATE

ECOA NOTICE (TO BE RETAINED BY APPLICATION) Thank you for your business credit application. We will review it carefully and get back to you promptly. 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 that statement, please contact us within 60 days from the date that you are notified of our decision. We will send you a written statement of the reasons for the denial within 30 days of 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 our compliance with this law is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580.

Please review the above information to ensure it is correct.