Capital Equipment Leasing Application Form

Applicant Contact

Important: Enter a valid e-mail address. Correspondance will be sent to this address.

First and Last Name*

Phone*

E-Mail:*

Referral Partner

Referral Partner Company

Referral Contact Name

Referral Contact Phone Number

Your Business Information

Full Legal Company Name*

Address Line 1:*

City:*

State:*

Zip Code:*

County:

Business Phone:*

Fax Number:

Cell Phone:

Nature of Business

(Industry Type)

Federal Employer Identification Number(EIN)

Business Established Date

Time in business under current ownership*

Location of Equipment

Vendor and Equipment Information

Amount Requested*

Equipment Description

Vendor Company Name

Preferred Lease Term

Purchase Option

Sales Representative`s Name

Sales Reps Phone

###-###-####

Sales Reps Email

name@email.com

Guarantor Information (and Business Stakeholders Owning 10% or more)

Principal Full Name:*

Title

Ownership Percentage:*

Home Phone Number:*

Home Address (Street):*

Home Address (City):*

State:*

Zip Code:*

Social Security Number:*

Principal Full Name:

Title

Ownership Percentage:

Home Phone Number:

Home Address (Street):

Home Address (City):

State:

Zip Code:

Social Security Number:

Bank Reference

Bank Name

Contact Person:

Phone:

Fax:

Account Type

Account Number:

How Long open?:

Acceptance

I DECLARE THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT, AUTHORIZE IT`S VERIFICATION

AND THE OBTAINING OF A CREDIT REPORT.

I understand any false or misleading statements in my application may cause any loan to be in default. I agree

that this application shall be this Institutions`s property whether or not this credit application is approved.

Please insure this form is signed by all guarantors on this application. By signing below, I stipulate that I agree to all of the terms and conditions stipulated on this application.

Signature:*

Title*

Dated:*

Signature:

Title

Dated:

Enter your first and last name in the signature space above.

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