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Vendor Information
Vendor Name:__________________________________________________________
Address:_____________________________City:________State:_______Zip:_______
Fax#:( )__________________________Telephone # ( )___________________
Lessee Information
Full Legal Name:_________________________________DBA____________________
Address:_____________________________City:________State:________Zip:_________
Years in Bus:._______#of employees:_____Contact person:___________ Title:_________
Nature of Business:________________________________________________________
Business Type: Corp____Prop._____Partner_____ LLC________
Personal Information
Officer:________________________Social Security: ____-____-_____
Title:_____________
Address:____________________________City_________
State __________Zip_________
Officer:________________________Social Security____-____-______Title____________
Address:____________________________Dity_________State__________Zip_________
Trade References
Name:__________________________________
Tel#( )______________Contact____________________
Name:__________________________________
Tel#( )____________Contact____________
Name:__________________________________
Tel#( )_____________Contact____________
Landlord Information
Name:__________________________________Tel#( )____________-Contact____________
Bank Information (two year history)
Bank Name:_____________________ checking______savings ________loan__________
Tel.#( )________________Contact name:__________________Acct#______________
Bank Name;_____________________checking_______savings________loan__________
Tel#( )________________Contact name___________________Acct#______________
Release authorization: Lessee hereby authorizes Lease One Corp.,and it's affiliates to obtain credit information from Banks, Trade References, Credit Reporting Services and Financial Institutions regarding credit worthiness. Every thing stated in this application is true and correct.
Authorization to Release to Banks: This my/our authorization for herein listed bank references to release any information requested as part of Lease One Corp.s normal credit procedures
._________________________________________________________________________
Signature Broker 110-125 Title Date
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