Applicants Name:

Email Address:    

Name of sales rep. If applicable:

Company Information

Company Name:

Street:

City:    State: Zip:

Fax: Phone:

When Was Company Established ? (Minimum 1Year In Business Required.)

Describe Business: -- Choose One -- S Corporation C Corporation Partnership Sole Proprietorship Limited Liability Company

Principal Of The Company

1. Name: Position:

    Street:

    City:    State: Zip:

    Social Security #:

Fax: Home Phone:

2. Name: Position:

   Street:

   City:    State: Zip:

   Social Security #:

Fax: Home Phone:

Bank References

1. Bank: Phone:

Contact Person:

Checking Acct #: Loan Acct #:

2. Bank: Phone:

Contact Person:

Checking Acct #: Loan Acct #:

Trade References

1. Company: Phone:

2. Company: Phone:

3. Company: Phone:

Landlord Reference

1. Landlord: Phone:

Other Lease Deals Under Contract

Do you currently have any lease obligations? (If Yes, Please give details below) Yes No

Name: Phone: Acct#

Name: Phone: Acct#

Describe Equipment You Would Like To Lease and Vendor Information

New Equipment Supplier Name:

Address: State: Zip: Phone:

Cost of equipment:    $    Term:  Months

Description of equipment. Please include other details we should know.

Who Referred You To Easy Leasing ?:

By submitting this application, I authorize Easy Leasing or its designees to pull a personal credit report on any persons listed above.

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