Submit Your Application

**This is not a secured site. You may print this application for completion and fax it to: 1-800-968-2808

Supplier Name: *

Salesperson: *

Supplier Phone: *

Supplier FAX:

Lessee:*

Contact: *

Address: *

Address2:

City: *

State: *

Zip: *

Phone

Fax

Equipment Description: *

Equipment Cost(w/o tax): *

Equipment Address (if different)

City:

State:

Zip:

Years in Business:

Nature of Business:

Rate Factor:

Monthly Payment:

Lease Term:

Purchase Option:

$1.00 Buyout

Fixed 10%

FMV

Business Type:

Corporation

Partnership

Proprietorship

Non-Profit

Bank Name:

Contact:

Phone:

Account Type:

Account No.:

Trade Reference 1:

Phone:

Trade Reference 2:

Phone:

Primary Principal:

Address:

City:

State:

Zip:

SSN:

Comments:

It is expressly understood that this constitutes an application only and in itself shall not be binding upon either party. Additionally, I/we authorize Ervin Leasing to investigate the bank, savings and loan and trade references listed, and if required by Ervin Leasing, to perform personal credit investigations on the corporate principal, partner, or proprietor listed above. Signature/Release: (Please sign and date)

Authorized Initials

* denotes required fields.