Lessee / Applicant Information

Legal Business Name / Lessee: Legal Business Name / Lessee:

Address: Address:

City: City:

Zip Code: Zip Code:

County: County:

Type of Business: Type of Business:

Federal ID#: Federal ID#:

Phone Number: Phone Number

Fax Number: Fax Number:

Cell Number: Cell Number

Contact: Contact:

Email Address: Email Address

Date Established / Time in Business: Date Established / Time in Business:

Annual Gross Revenues: Annual Gross Revenues:

Equipment Location (if different from above): Equipment Location (if different from above):

Principal Information (President, Owner or Partners)

Name 1: Name 1:

Address: Address:

City: City:

State: State:

Zip Code: Zip Code:

SSN: SSN:

Home Phone: Home Phone

% of Ownership: % of Ownership:

Name 2: Name 2:

Address: Address:

City: City:

State: State:

Zip Code: Zip Code:

SSN: SSN:

Home Phone: Home Phone

% of Ownership: % of Ownership:

Vendor / Equipment Information

Vendor: Vendor:

Vendor Address: Vendor Address:

Vendor City and State: Vendor City and State:

Vendor Zip Code: Vendor Zip Code:

Description of Equipment: Description of Equipment:

Total Cost (w/o tax): Total Cost (w/o tax):

Vendor Phone Number: Vendor Phone Number

Contact: Contact:

Terms (months): Terms (months):

All information in this application and all attachments is correct to the best of my knowledge. I authorize verification of employment and all financial and other information submitted with this application, including obtaining a credit report, to act on this application. I authorize making continued inquiries about such information and obtaining a credit report during the term of my lease(s) as necessary to administer my lease(s). As required by law, my identity will be verified. I authorize all past or present creditors to release any and all necessary credit information, and to respond fully to requests for information based on this application when transmitted by electronic or other means. I authorize any lessor making a lease applied for hereby to disclose to you, on a confidential basis, my personal, credit and other information (including without limitation post-closing information regarding the servicing of the lease and any defaults thereunder), whether or not you are a servicer of the lease. The above permissions and authorizations will apply to any creditor to whom this application is submitted. I certify that the lease(s) applied for hereunder are for business, commercial or agricultural purposes and not for personal, family or household purposes. 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 that 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. A number of federal agencies share enforcement responsibility for this law. Determining which agency to contact depends on the type of creditor you dealt with. Consult the creditor to whom this application is addressed for information on its regulator, or contact The Federal Trade Commission, Consumer Response Center, Washington, D.C. 20580, 1-877-382-4357.

Authorized Signer: Authorized Signer:

Second Authorized Signer: Second Authorized Signer:

Title: Title:

Second Signers Title: Second Signers Title: