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LeaseGenie.Com Application

Company Name:
Nature of Business:
Company Contact Person:
Title:
Company Address:
Company City:
Company State:
Company Zip Code:
Company Telephone:
Company Fax:
Structure (Corp) (Partnership) (Proprietorship) (LLC) (Other):
Time in Business:
Company Email:
Company Website:
Principal (#1):
Principal #1 Address:
Principal #1 City:
Principal #1 State:
Principal #1 Zip Code:
Principal #1 SSN:
Principal #1 Telephone:
Principal #1 Date of Birth (MM/DD/YY):
Principal (#2):
Principal #2 Address:
Princiap #2 City:
Principal #2 State:
Principal #2 Zip Code:
Principal #2 SSN:
Principal #2 Telephone:
Principal #2 Date of Birth (MM/DD/YY):
Bank (#1):
Bank #1 Contact:
Bank #1 Telephone:
Bank #1 Fax Number:
Bank #1 Type Account (Checking) (Savings):
Bank #1 Account #:
Bank (#2):
Bank #2 Contact:
Bank #2 Telephone:
Bank #2 Fax Number:
Bank #2 Type Account (Checking) (Savings):
Bank #2 Account #:
Trade / Credit Reference (#1):
Ref. #1 Contact:
Ref. #1 Account #:
Ref. #1 Telephone:
Ref. #1 Fax Number:
Ref. #1 City:
Ref. #1 State:
Trade / Credit Reference (#2):
Ref. #2 Contact:
Ref. #2 Account #:
Ref. #2 Telephone:
Ref. #2 Fax Number:
Ref. #2 City:
Ref. #2 State:
Description of Equipment:
Amount Requested:
New or Used:
Estimated Delivery Date:
Vendor Name:
Vendor Address:
Vendor City:
Vendor State:
Vendor Zip Code:
Vendor Contact:
Vendor Telephone:
Vendor Fax Number:
Vendor Mobile:
Vendor Email:

The individual completing this form represents and warrants that by submitting this application that all credit and financial information submitted herewith is true and correct and is informed that in connection with this application an inquiry may be made as part of a normal investigative procedure and hereby authorizes Lease Genie or others to conduct such an investigation.