| COMPANY NAME :_______________________________________ |
THE VENDOR:_______________________________ |
| ADDRESS_____________________________________ | ADDRESS___________________________________ |
| CITY______________________ ST_____ ZIP_________ | CITY_____________________ ST_____ ZIP_______ |
| PHONE_________________ FAX__________________ | PHONE_________________ FAX________________ |
| E-MAIL____________________ YRS IN BUSINESS____ | SALES REP__________________________________ |
| TYPE OF BUSINESS_____________________________ | DELIVERY DATE_________________________ |
| CONTACT __________________EIN #_______________ | SHIP TO (IF DIFFERENT)______________________ |
| CHECK ONE: ___Proprietorship ___Partnership ___LLC ___C-Corp ___S-Corp ___ Non-Profit | |
| THE PRINCIPAL(S): | RESIDENCE ADDRESS | SOC. SECURITY # |
| ___________________________ | ___________________________________ | _____-____-_______ |
| ___________________________ | ___________________________________ | _____-____-_______ |
| By signing below, the undersigned
individual, who is either a principal of the credit applicant or a personal
guarantor of its obligations, provides written instruction to Lessor or its designee (and any assignee or potential assignee thereof) authorizing review of his/her personal credit profile from a national credit bureau. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for the purposes of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account. A photostat or facsimile copy of this authorization shall be valid as the original. By signature below, I/we affirm my/our identity as the respective individual(s) identified in the above application. |
||
X___________________________________________________________ X_____________________________________________________________
| BANK & BRANCH:____________________________ | CONTACT NAME_____________________________ |
| TELEPHONE__________________________________ | ACCOUNT NUMBER(S)________________________ |
TRADE REFERENCES: (Extending Credit) |
Contact or A/C# |
Phone |
| _____________________________________ | ____________________ | _____________________ |
| _____________________________________ | ____________________ | _____________________ |
| _____________________________________ | ____________________ | _____________________ |
FINANCIAL INFORMATION: - Needed over $100,000 and often gain preferred rate on smaller packages |
|||
| STATEMENTS | ___ ATTACHED | ___ WILL FORWARD | ___ NOT AVAILABLE |
| TAX RETURNS | ___ ATTACHED | ___ WILL FORWARD | ___ NOT AVAILABLE |
EQUIPMENT DESCRIPTION: |
COST |
LEASE TERM |
PURCHASE OPTION |
| _____________________________________________ | $___________ | _____ MO | ___ 10% ___$1.00 |
AUTHORIZATION: - Please sign at the "X" |
| I authorize all deposit,
borrowing, and trade information to be released to
KEYSTONE LEASING and its affiliates .I have
read and understand the Notices below. I hereby represent all information is true, correct and complete. A photostatic copy or facsimile of this authorization shall be valid as the original. Signature of Officer X______________________________________ Title____________ Date _____________ |
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NOTICES
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, or age (provided the applicant has the capacity to
enter into a binding contract); or 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 concerning this creditor 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 the President of Keystone Equipment leasing, Inc. at the above address and telephone, 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.
Portions Copyright KEYSTONE EQUIPMENT LEASING, INC. 2001