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  Online Lease Application

 
Please fill in all fields marked with a *
General Information
Lessee Name *
Address
(Please Include City, State and ZIP Code)
*
Phone *
E Mail *
Contact Person *
Cell Phone *
Equipment Location *
Type Of Business *
Time In Business *
Business Type *
Dun & Bradstreet Number *
Federal Tax ID *

Banking Information
  Bank 1      
Bank Name * Business Checking Account # *  
Contact Person * Bank Phone #                      *  
  Bank 2
Bank Name Business Checking Account #
Contact Person Bank Phone #                     

Trade References
  Supplier Reference 1    
Supplier Name * Supplier Contact               *
Supplier Phone # *  
  Supplier Reference 2  
Supplier Name Supplier Contact                 
Supplier Phone #
  Supplier Reference 3  
Supplier Name Supplier Contact                 
Supplier Phone #
     
Landlord Name *
Landlord Contact *
Landlord Phone *

Personal Information
Name *
Social Security Number *
Home Phone *
Home Address
Please Include City, State, and ZIP Code
*

Equipment Information
Equipment To Be Leased *
Equipment Cost *
New
Used
Lease Term *
Vendor Name *
Vendor Address *
Vendor Contact *
Vendor Phone *

PLEASE READ BEFORE CONTINUING

Disclaimer
By submitting an online credit application, you (a) represent that all information provided in the application is true, accurate and complete in all material respects; (b) represent that you are in fact, the individual as to whom such information pertains or an authorized representative of the business entity to which such information pertains; (c) represent that you are 18 years of age or older; (d) represent that you expressly authorized the release of credit information from any source including credit reporting agencies and your bank for the purpose of extending credit and updating your account from time to time; and (e) represent that the proposed transaction is intended solely for business or commercial 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 the applicant has the capacity to enter into a binding contract), because all or part of the applicants 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 compliance with this law is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580.

By checking this box, you have read and agree to the terms above: