CUSTOMER INFORMATION

Full Legal Name:   Phone #: Fax #:

Doing Business As:Federal Tax ID#Year Business Established:

Business Address:City: State: Zip: Company Type: Proprietorship Partnership Franchise Corporation Other

BANK REFERENCE

Bank Name: Account #:Contact:

Phone Number: Fax #:

LESSEE AUTHORIZATION

First Name:Initial: Last Name: Home Phone #:

Social Security Number: Home Address: 

City: State: Zip:

TRADE AND LANDLORD REFERENCES

Trade Reference Name: Phone #: Contact:

Landlord Reference name:Phone #: Contact:

EQUIPMENT LEASE INFORMATION:

Lease Term: 12 months 24 months 36 months 48 months 60 months

End of Lease Options: Fair Market Value 10% purchase Option $1.00 Purchase Option

$ Lease Amount:*Required

Enter a description and purchase amount of the equipment to be leased in the form below

I authorize the Lessor or its agent to investigate my personal credit and financial records.