Equipment Lease Application

Leasing Specialists, Inc. 2701 Grand Avenue Galesburg, IL 61401

Phone: (309) 343-2099 Fax: (309) 343-2098 Website: www.lease-today.com
APPLICANT INFORMATION
Name*
Email*
example@example.com
Phone*
Years In Business*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security No*
Check One*

TaxableTax Exempt

EQUIPMENT TO BE LEASED

SUPPLIER INFORMATION (Source of Equipment Being Purchased For Lease: Dealer, Private Party, Auction)
Supplier*
Phone*
Address
Contact
LEASE DETAILS
Purchase Price
Lease Term (Years)
Check One: Annual Payments*

AnnualSemi-Annual PaymentsQuarterly Payments

BANK REFERENCES*

	Bank	Phone Number	Contact Person	City & State

TRADE REFERENCES (Suppliers, Equipment Dealers, Landlords) - 3 Minimum*

EQUIPMENT INSURANCE
Agency*
Agent*
Fax (need either email or fax) - OR -
Please enter a valid fax number.
Email
example@example.com
Address*
Phone*
The Following Information Should Accompany This Application:
Drivers License, Recent Financial Statements, Prior Two (2) Years Tax Returns.

I/we have applied for a lease from Leasing Specialists, Inc (LSI I/We authorize LSI, its officers, employees, and agents, to make all inquiries that LSI deems necessary in its sole discretion to determine my/our credit worthiness, including but not limited to procurring credit reports and credit information from credit reporting agencies, financial institutions, extenders of credit references, and my/our present and former employers, suppliers, merchants, landlords, and grain merchants creditors. I/We agree that a photostatic or facsimile copy of this Authorization shall be considered as effective and as valid as the original. I/We hereby certify under penalty of law that the foregoing is true and complete information.

The undersigned declares that he/she has read and understands the information above.
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