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CORPORATE INFORMATION

Company Name

DBA Name

Street

City

State

Zip code

Cell Phone Number

Contact Name

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

Zip code

Phone Number

Sale Rep

EQUIPMENT INFORMATION

Equipment Cost

Lease Term

Purchase Option

$1.00

FMV

Prepaid

Equipment Description

BUSINESS OWNER INFORMATION

Name

Title

Street

City

State

Zip code

Home Phone Number

Social Security Number

%Owned

More than one owner?

Yes

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.

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CORPORATE INFORMATION

VENDOR INFORMATION

EQUIPMENT INFORMATION

BUSINESS OWNER INFORMATION

AUTHORIZATION TO RELEASE INFORMATION:

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