Lessee

Legal Business Name
 
Address
 
City
State
Zip
Phone
Contact
Email
Type of Business
Years in Business
 

Owner Information

  Prop     Corp    Ptshp
 
Federal Tax ID #
 
Officer Name
 
Title
 
Address
 
SS#
 
City
State
Zip
 
Officer Name
 
Title
 
Address
 
SS#
 
City
State
Zip
 

Vendor Information

Contact
 
Phone
 
Equipment
 
Projected Cost $
 
Term     36     48
 

Bank

Bank should be at least two (2) years old. If less, please supply a previous bank reference
 
Bank
 
Contact
 
Account # - Business Checking
 
Phone
 
Other Banking Reference
 

Trades

Name
 
Contact
 
Phone
 
Name
 
Contact
 
Phone
 
Name
 
Contact
 
Phone
   By checking yes, the individual submitting this form, recognizing that his/her individual credit history may be a factor in the evaluation of the credit of the applicant, hereby consents to and authorizes the above named business credit provider and any assignee, lender or funding service that may be utilized to obtain and use a consumer credit report on the undersigned, now and from time to time, as may be needed in the credit evaluation and review process and waives any right or claim they would otherwise have under Fair Credit Reporting Act in the absence of this continuing consent.