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VENDOR / DEALER INFORMATION
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VENDOR / DEALER NAME
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VENDOR / DEALER ADDRESS
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DATE:
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Phone Number (
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Fax Number ( )
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Contact Name
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EMAIL
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EQUIPMENT DESCRIPTION
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Itemize Maintenance, Services, Training, Installation, if
applicable
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Quantity
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Manufacturer
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Model Number
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Description
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NEW
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USED
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Equipment Cost
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TOTAL COST =>>
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TERM/LEASE PAYMENT SCHEDULE
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TERM of LEASE
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#
ADVANCE PAYMENTS 1 or 2
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PMT
Factor
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Monthly Dollar Payment
(Based on Cost Shown in TOTAL COST
above)
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(If Applicable) SECURITY DEPOSIT %
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Lease End Purchase Option
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ENTER # of MONTHS
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ENTER PERCENTAGE %
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$1.00
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FMV
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10%
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Other
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CUSTOMER INFORMATION
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Lessee Business or Entity Name ( Legal Name followed by DBA )
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Lessee Phone #
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FAX #
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EMAIL
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Lessee Address 1
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Lessee Address 2
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STATE
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ZIP CODE
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Signer Name & Title
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Tax
ID #
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Nature of Your Business
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Year Started=>
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<= Corporation
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<=Partnership
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<=Sole Proprietor
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<=LLC or PC
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Annual revenue over $1 million? TYPE "YES or "NO" >>
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Estimated Monthly Gas and Electric Bill (Optional)
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REFERENCES
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Bank Name
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Account No.
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TYPE of ACCOUNT ie. Checking or Loan, Lease,
Revolving Credit Line
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Bank Phone No.
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Bank Contact Name
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Title
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City
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STATE
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Trade Reference 1
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Phone No.
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Trade Reference 2
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Phone No.
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Account No.
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Contact
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Account No.
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Contact
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PERSONAL INFORMATION ON PARTNERS, PROPRIETORS, OR
GUARANTORS
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Name
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Name
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Title
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Social Security No.
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Title
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Social
Security No.
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Street Address
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CITY & STATE
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Street Address
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CITY & STATE
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County
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Zip Code
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County
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Zip Code
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AUTHORIZATION
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DATE:
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The undersigned individual(s) who is either a
Principal, Sole Proprietor, or
Personal Guarantor of the
Credit Applicant, recognizing that his or her individual credit history
may be a factor in the evaluation of the credit history
of the Applicant or in the evaluation of his or her personal guaranty, if applicable, hereby consents to and
authorized the use of a
consumer credit report on the undersigned individual(s) by the above named business credit grantor, from time totime as may
be needed, in the initial credit evaluation and subsequent review processes.
I/we stand advised that the Advance Payment or Security Deposit is not
refundable unless this application is rejected by Lessor.
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Partner, Proprietor or Guarantor SIGNATURE
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Partner, Proprietor or Guarantor SIGNATURE
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X
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X
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NOTICE
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If your application for business credit is denied,
you have the right to a written statement of the specific reasons for the
denial. To obtain the statement, please call (609) 654-1231 within 60 days
from the date you are notified of our decision. We will send you a written
statement of reasons for the denial within 30 days of receiving your request
for the statement. NOTICE: The Federal Equal Credit Opportunity Act prohibits
creditors from discriminating against credit applicants on the basis of race,
color, religion, national origin, sex, martial status, age (provided the
applicant has the capacity to enter into a binding contract); because all or
part of the applicant’s income derives from any public assistance program; or
because the applicant has in good faith exercised any right under the
Consumer Credit Protection Act. The federal agency that administers
compliance with the law concerning the creditor is the Federal Trade
Commission, Equal Credit Opportunity, Washington, D.C. 20580.
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