LESSEE / APPLICANT INFORMATION

ACCESS EQUIPMENT & FINANCING LLC

LEASE APPLICATION – Fax: 937-676-2509 or Call 866-892-0315

LESSEE / APPLICANT INFORMATION

Legal Business Name/Lessee

Phone

Address (Street, R.R. - no PO Box)

Fax

City County State Zip

Contact

Lessee is a (Check appropriate box)
Corporation Partnership Proprietorship Other

Equipment Location (If different than above)

Date Business Started

Nature of Business

Sales Tax Exempt
Yes Or No

Federal Tax ID Number

PRINCIPAL INFORMATION (President, Owner or Partners)

Name (1)

Title

Name (2)

Title

Social Security Number

Home Phone Number

Social Security Number

Home Phone Number

Home Address

City State Zip

Business Bank Name

City & State

Bus. Checking Account #

Bank Phone #

Business Bank Name

City & State

Bus. Checking Account #

Bank Phone #

Trade Reference

City & State

Trade Reference Acct

Phone Number of Trade

Trade Reference

City & State

Trade Reference Acct

Phone Number of Trade

Insurance Agent

City & State

Contact

Phone Number

Landlord/Mortgage

City & State

Contact

Phone Number

VENDOR / EQUIPMENT INFORMATION

Phone

Contact

Address City State Zip

Fax

Equipment
To Be
Leased -

Term (months)

Advance Payments

Buyout Option
FMV 10% $1

Sales Tax Rate

Total Cost (Without Tax)

Used

New

Description of Equipment

I would like a FREE shipping quote: Yes No

I consent by placing my signature (s) below, that the information stated above is true. I authorize the release of all credit information credit bureaus reports, loans, lease, checking, saving and trade account information on the individuals below to Access Equipment & Financing LLC, and to its assignees or potential assignees. I authorize that a photocopy or a facsimile copy of this release can be valid as the original.

Signature #1:_____________________________ Date__________ Signature #2:______________________________ Date __________

Tony Blundell form 7-3