Credit Application

To download a PDF of the application: Download PDF Credit Application

 

 

 

Borrower/Lessee

What type of company is this application for:

Company name

DBA

Fed Tax ID

State of Incorporation

D&B# (Dun & Bradstreet)

Address Line 1


Address Line 2


City


State


Zip


Telephone


Contact Name


Direct Line


Fax Number


Email Address


Website


Business Description


Time in Business Under Current Ownership (Years)


Business Type


Vendor

Company name


Address Line 1


Address Line 2


City


State


Zip


Telephone


Fax Number


Contact Name


Email Address


Comments


Bank Reference

Principal Bank


Account Number


Bank Telephone


Contact


Personal Information on Officers, Partners or Owners

Name (First, MI, Last)


Home Address Line 1


Home Address Line 2


City


State


Zip


Telephone


Percentage (%) of Ownership


SSN




Name (First, MI, Last)


Home Address Line 1


Home Address Line 2


City


State


Zip


Telephone


Percentage (%) of Ownership


SSN



Trade References

Company Name


Telephone


Contact Name



Company Name


Telephone


Contact Name


New Equipment to be Financed (attach equipment schedule if necesasary)

Address of Installation Line 1


Address of Installation Line 2


City


State


Zip



Quantity


Model


Serial No.


Equipment Value


Description



Quantity


Model


Serial No.


Equipment Value


Description



Choose File


Choose Files


Proposed Finance Terms

Number of Installments (Months)


Financing Type


Lease Purchase Option



* Complete financial statements may be required for all transactions exceeding $100,000.
I hereby represent all information is true, correct and complete. By placing my/our full name and date of birth in the indicated boxes you affirm your signature to be acceptable as a written signature. I/we authorize the release of any credit information, business or personal to be released to the Lender/Lessor or its assigns. Lender/Lessor complies with section 326 of the US Patriot Act. This law mandates that Lender/Lessor or its assigns request and verifies certain information about you and your company. A copy or fax of this authorization shall be valid as the original.


Electronic Signature #1



(Type Authorizing Officer Name)

Date Of Birth



(MM/DD/YYYY)

Title


Today's Date



(MM/DD/YYYY)

Electronic Signature #2



(Type Authorizing Officer Name)

Date Of Birth



(MM/DD/YYYY)

Title


Today's Date



(MM/DD/YYYY)


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