Supplier Information
*Supplier Name
*Mailing Address *City
*State *Zip Code

Quote/Ref Number
*Quote/Ref Number
Lessee Information
*Business Name
(Exact Legal Name)
*Federal ID#
*Address *City
*State *Zip Code
*Phone Fax
Email
State of Incorporation
*Contact Person Title
Telephone
(If Different From Above)

Equipment Description
*Quantity
New/Used
*Description (Include Accessories)
Comments
Equipment Location (If Different From Above)
Address City
State Zip Code

Transaction Structure
Purchase Option FMV $1 10%
*Initial Payment $ Advance Security Deposit
Exempt From Personal Property Tax Yes No
Payments are MONTHLY unless otherwise indicated
*Term (in months) *Equipment Cost (before tax)
Lease Payment (before tax) Freight
Documentation Fee Other
TOTAL COST (before tax)

Credit Information
Nature of Business
*Years under current Ownership # of Emp
*Business Type
Corporation Partnership Proprietorship
Other (Describe)

BANK(S) (Previous bank is required if applicant has been at present bank less than 2 years)
Bank #1
Name Phone
Account # Type
Bank #2
Name Phone
Account # Type

TRADES (Do NOT include credit cards, utility companies, landlord, non-business references)
Name #1
Name Phone
Name #2
Name Phone
Name #3
Name Phone
Name #4
Name Phone

PERSONAL INFORMATION If closely-held corporation, partnership or proprietorship or less than 50 employees or in business less than five years, please provide the following on principals, including signatures.
Name #1
Name Social Security #
Home Address
City
State Zip Code
Name #2
Name Social Security #
Home Address
City
State Zip Code

*Verification Type the characters you see in the box below.


Letters are not case-sensitive