* Business Phone:

* Business Fax:

* City:

* State:

* Zip Code:

Federal I.D. No:

* Date Started:

* Type of Incorporation/ Ownership:

* Type of Business:

Alternate Phone Number:

* Title:

* Ownership %:

* SSN Number:

Home Phone:

Cell Phone Number:

Date of Birth:

Driver's License #:

* Email Address:

* Purchase Price:

I/we hereby authorize you to whom this application is made, or your agents, to investigate my/our credit worthiness and will provide financial statements, tax returns, etc., as you deem necessary. I/we agree that the advance payments under the lease are not refundable unless the lessor rejects the application. By the execution of the lease agreement, I/we warrant that the information submitted herein is true and correct and hereby authorize references contained herein to release any necessary information. Further, I/we warrant it is understood that lessor reserves the right to reverse any credit decision if the information contained herein is found to be incorrect, and I/we will indemnify lessor for any and all costs incurred with this application for credit including any cost incurred in the placement or reservation of the intended leased equipment based on the information contained herein. Submitting this application is equivalent to a signature.