REPOWR Credit Application

Credit Application

Equipment Rentals On-Demand, with REPOWR
Company Name *

Legal Name of Entity In Business Since
Legal Formation of Entity *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
E-mail of Person Completing Form *
example@example.com
Phone Number *
Please enter a valid phone number.
Pickup or Delivery? *

Pickup at Rental Location Deliver to my location
Pickup / Delivery Date & Time
*If delivery, please specify location: (street address, city, state, zip)
Special Requests

Bank Reference
Name of Institution *
Checking Account # *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Trade References

Trade Reference I
Company Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Trade Reference II
Company Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Trade Reference III
Company Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com

W-9 Form (Required)

Please submit your W-9 Form with your Credit Application
Upload your W-9 *

Cancel of
Insurance Requirements
Auto Liability: $1,000,000

General Liability: $1,000,000

Physical Damage / Trailer Interchange Coverage

*Certificates of Insurance must name the equipment owner as Additional Insured.

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, i hereby authorize the financial institutions listed in this credit application to release necessary information to the company for which credit is being applied for in order to verify the information contained herein.

By signing and submitting this application, you provide consent to authorize REPOWR, equipment owner, and financial institutions to perform necessary credit check for consideration of renting, leasing, buying, or selling equipment.

This application may be executed and delivered by electronic (facsimile, email, .pdf, etc.) transmission shall constitute effective execution and delivery hereof and all purposes and signatures hereto transmitted and / or produced electronically shall be deemed to be their original signature for all purposes.

REPOWR, LLC shall not be held liable for accurate information included in this application.

Name

First Name Last Name
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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