Online Leasing Application
Natesh Agate | 866.615.6262 ext. 441
Primary Contact:
Email Address:
Legal Company Name:
Phone Number:
Fax Number:
State of Incorporation:
Tax ID #:
Business Structure:
Type of Business:
Years in Business:
Declared Bankruptcy?:
Authorized Signer:
Title of Signer:
Equipment Address:
Equipment City:
Equipment State:
Equipment Zip:
Type of Equipment:
Approx. Value ($):
Sales Representative:
Principal 1 Name:
Phone Number:
Social Security #:
Date of Birth:
Month:       Day:      
Ownership %:
Own/Rent Home :
I hereby certify that the information contained in this lease application is true and accurate and I hereby authorize our banks, trade references, and financial institutions the right to release credit information. In states where permissible, I hereby authorize the filing and recording of UCC financing Statements showing the Secured Party's interest in the equipment and grant the Secured Party the right to execute Lessee's/debtors name thereto. A Photostat copy of this authorization shall be as valid as the original.
The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital 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 this law is the Federal Trade Commission Equal Credit Opportunity, Washington, D.C. 20580. 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 contact Lessor set forth above within 60 days from the date you are notified or our decision. We will send you a written statement of reasons for the denial within 30 days for receiving your request for the statement.

Notice: To help the government fight the funding of terrorism and money laundering activities, U.S. Federal law requires financial institutions to obtain, verify and record information that identifies each person (individuals or businesses) who opens an account. What this means for you: When you open an account or add any additional service, we will ask you for your name, address and taxpayer identification number that will allow us to identify you. We may also ask to see other identifying documents.