• Lessee - Company 

	Company Name:
	Address:

	City: State: Zipcode

	Daytime Phone:  ()
	Fax Number:   ()
	Email Address:
	Time in business: Fed Tax Id #:
	Equipment Location:
	If Other Explain:

• Officers' Names and Titles: (President, Executive, Director, Etc.)

Name # 1: Title:

	Address:
	City:   State: Zip

	SS#:
	Percent Ownership:

 

Name # 2: Title:

	Address:
	City:   State: Zip

	SS#:
	Percent Ownership:

.

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• Desired Equipment

	Description Of Equipment:
	Quantity:
	New Used
	Amount of Lease/Leasing Line of Credit:
	Term of lease requested (months):
	Equipment Location:

• Bank References

Bank #1:

	Name:
	Address:
	City:State:Zip:
	Checking Account #:
	Contact:
	Telephone #:    ()
	Fax Number: ()
	Loan Account #:

• Lease/Loan Credit References

Credit Reference #1:

	Name:
	Telephone #: ()
	Fax Number: ()
	Contact:
	Account#:

Credit Reference #2:

	Name:
	Telephone #: ()
	Fax Number: ()
	Contact:
	Account#:

• Trade References

Trade Reference #1:

	Name:
	Address:
	City:State:Zip:
	Telephone #: ()
	Fax Number: ()
	Contact:

Trade Reference #2:

	Name:
	Address:
	City:State:Zip:
	Telephone #: ()
	Fax Number: ()
	Contact:

 

Trade Reference #3:

	Name:
	Address:
	City:State:Zip:
	Telephone #: ()
	Fax Number: ()
	Contact:

• Vendor

	Vendor:
	Name:
	Address:
	City:State:Zip:
	Telephone #: ()
	Fax Number: ()
	Contact: