EQUIPMENT LEASING APPLICATION	
B
U

B	BUSINESS NAME/LESSEE
	Phone:
Email:
 Fax	
S
I
	ADDRESS (STREET)
 	(CITY)	(STATE)
	(COUNTY)
	(ZIP CODE)
	
N
E
	TYPE OF BUSINESS
	DUNNs NUMBER
	DATE BUS. BEGAN
	FED. TAX NO.
	
S
S
	LOCATION OF EQUIPMENT (STREET)
	(CITY)
	(STATE)
	(COUNTY)
	(ZIP CODE)

	
	STRUCTURE:	      Proprietorship   S-Corp    LLC	 Public Corp.      Partnership  	
				
O
W
	PRINCIPAL’S NAME
  	TITLE
	% OWNERSHIP
	HOME PHONE NO.
	SOC. SEC. NO.
	
N
E
	HOME ADDRESS (STREET)
  	(City
	(STATE)
	(ZIP CODE)
	 OWN
  RENT	DRIVER’S LIC. NO.	
R
S
	PRINCIPAL’S NAME
	TITLE
	% OWNERSHIP
	HOME PHONE NO.
	SOC. SEC. NO.
	
H
I
	HOME ADDRESS (STREET)
   	(CITY)	(STATE)
	(ZIP CODE)
	  OWN
  RENT	DRIVER’S LIC. NO.	
P
	PRINCIPAL’S NAME
  	TITLE
	% OWNERSHIP
	HOME PHONE NO.
	SOC. SEC. NO.
	
	HOME ADDRESS (STREET)
    	(CITY)
	(STATE)
	(ZIP CODE)
	  OWN
  RENT	DRIVER’S LIC. NO.	
			
	BANK
	BRANCH

	Contact
	Phone  
Fax 	

B
	ACCOUNT UNDER NAME OF
	CHECKING ACCT. NO.
	SAVINGS ACCT. NO.	LOAN ACCT. NO.	
A
N
	BANK
	BRANCH

	Contact
	Phone  
Fax 	
K
S
	ACCOUNT UNDER NAME OF
	CHECKING ACCT. NO.
	SAVINGS ACCT. NO.	LOAN ACCT. NO.	

					

E
Q
	VENDOR
	CONTACT
	
U
I
	ADDRESS (STREET)
	(CITY) 
	(STATE)
	(ZIP CODE)
	TELEPHONE
	
P
M
	EQUIPMENT TO BE LEASED
New   Used   Demo  	
N
T
	COST OF EQUIPMENT
$ 	TERMS OF LEASE
 MONTHS	RATE / MO. PAYMENT
	DEPOSIT RECEIVED

I hereby authorize the leasing company it’s nominees and/or assigns, to investigate the references herein listed or statements or other data obtained from me or from any other persons pertaining to my credit and financial responsibility.	
X__________________________________
SIGNATURE/TITLE	
__________
DATE	

**PLEASE PROVIDE US WITH THE FIRST PAGE OF THE LAST THREE BANK STATEMENTS ON THE BUSINESS.