Loans And Finance Application

Business Information

Business Name/Lessee

Address

City, State, Zip

Phone

Fax

Mobile

Location of Equipment

Contact Name

Email Address

Annual Sales

Sales Tax?

Declared Bank

Type of Ownership

State of Incorporation

Any other State?

Time in Business

Ownership

Principal Name

Title

Social Security #

% Ownership

Home Phone

Home Address

City, State, Zip

Housing

Rent Own

Bank Reference

Bank Name

Bank Branch

Account #

Account Name

Bank Phone

Bank Email

Type of Account

Checking Savings Loan

Loan

Loan/Leasing Co.

Account #

Phone

Original Loan

Start Date

Monthly Payment

Trade Reference

Company Name

Address

City, State, Zip

Contact

Phone

Bank Referral

Company Name

Address

City, State, Zip

Contact

Phone

Equipment Information

Equipment to Purchase

Equipment Cost

Supplier

Contact

Phone

I hereby certify that the information contained in this lease application is true and accurate and I hereby authorize our banks, trade references, and financial institutions the right to release credit information, In states where permissible. I hereby authorize the filling and recording of LICC financing Statements showing the Secured Party's interest in the equipment and grant the Secred Party the right to execute Leasee's/debtors name thereto, A photostat copy of this authorization shall be as valid as the original.

Agree Disagree