CREDIT & LEASE APPLICATION Representative:   Date:

Business
Business Name/Lessee		Phone:
Address		Fax:
City	State:  Zip:	D&B
Location of Equipment if other than above, time in business at each additional location.		Corp  Part  Prop  LLC
Type of Business  Age of Business Number of Employees  Federal Tax Number Name of Corporate Secretary Install Date Date of Incorporation State of Incorporation Comments

Ownership
Principal or Officer (1)	Spouse	Title	% Owned	Social Security Number
Home Address	City	State	Zip	Home Phone
Principal or Officer (2)	Spouse	Title	% Owned	Social Security Number
Home Address	City	State	Zip	Home Phone

Banks
Bank/Branch	Date Opened	Account Number	Loan Number	Phone	Contact Officer

Trades
Trade References	Date Opened	High Credit	City, State	Account	Phone	Contact

Vendor
Vendor Name			Phone Number		Fax Number
Address		City	State	Zip	Home Phone
Equipment to be leased			Condition report may be required New Used		Equipment Cost
			% Tax		Tax Amount
Rate Factor	Term		Advance Payments		Total Cost

I hereby certify: (i) the information provided above is true and correct, (ii) you are hereby authorized to investigate all bank, credit and trade references, and said references are hereby authorized to release any requested information to you or your nominee, (iii) such authorization shall extend to obtaining personal credit profile in considering this application and subsequently for the purposes of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account, (iv) this information may be transmitted by us to you and by you to underwriter/s for the purpose of granting to me credit, either electronically or manually, and that by submitting this application, I take full responsibility for transmission thereof, (v) I am over 18 years of age, (vi) I acknowledge my rights under the Fair Credit Opportunity Act, and (vii) this request is for business and not consumer purposes.

Signed:		Title:		Date:
Signed:		Title:		Date:
Signed:		Title:		Date: