Lessee Company Information

Legal Business Name
Phone Number
Fax Number
Cell Number
Contact Name
Nature of Business
Address
City
State
Zip
E-mail
Authorized Signer
Title
Type of Business	Proprietorship LLC Corporation Partnership Other
Date Established
Tax Exempt	No Yes
If Exempt, Why?

Owners or Officers

Name		Name
Title		Title
Social Security #		Social Security #
Home Phone		Home Phone
Home Address		Home Address
City		City
State		State
Zip		Zip
Employer		Employer
Time Employed		Time Employed
Income/Year		Income/Year
Own or Rent?	Own Rent	Own or Rent?	Own Rent
Monthly Expenses		Monthly Expenses

Company Bank Reference       

Bank Name or Branch
Relationship in Years
Chkg/Loan Acct #
Bank Telephone
Bank Contact

Company Trade References

Name		Name
Address		Address
Phone Number		Phone Number
Fax Number		Fax Number
Contact		Contact
Acct #		Acct #

Vendor and Equipment Information

Vendor Name/Contact
Vendor Address
Vendor City
Vendor State
Vendor Zip
Telephone
Fax
Vendor Guaranty?	Yes No
Equipment Cost
Term (Months)	12 24 36 48 60
Equipment Description and Intended Use
Equipment Location

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