Company Information
Business Legal Name
*
DBA (if applicable)
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Federal Tax ID
*
Legal Structure
*
Sole Proprietorship
Partnership
LLC
Corporation
Municipal
Not for Profit
Year in Business
*
Number of Employees
*
Industry Type
Website
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Equipment Information
Vendor
Equipment Model
*
Finance Amount
*
Equipment Condition
*
New
Used
Term (in months)
*
Please Select
24
36
48
60
72
84
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Business Owners or Officers
* At least one contact is required
Name
*
First Name
Last Name
Title
*
Please Select
Owner
Partner
Member
C-Level Office
President
Vice President
Director
Controller
Manager
% Ownership
*
Please Select
0%
Less than 50%
50%
More than 50%, less than 100%
100%
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Additional Business Owners or Officers
* If applicable
Name
First Name
Last Name
Title
Please Select
Owner
Partner
Member
C-Level Office
President
Vice President
Director
Controller
Manager
% Ownership
Please Select
0%
Less than 50%
50%
More than 50%, less than 100%
100%
Phone Number
Please enter a valid phone number.
Email
example@example.com
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Additional information
Anything else you would like to tell us about your business or about this credit application
Terms & Conditions
By clicking "Accept" and submitting this Application, each owner, officer or guarantor listed above agree, individually and as the duly authorized representative of the business-applicant i. that all information provided in this Application is true, correct and complete, ii. that the property leased or any credit extended by Ascentium Capital LLC (“Ascentium”) will be used solely for business and commercial purposes and iii. that Ascentium is authorized to email information about financing, promotions, and other offers to the email address listed above. The business-applicant and each owner, officer or guarantor listed above further authorize Ascentium or its successors, assigns or one or more alternate third-party funding providers to investigate its organizational and personal credit histories, including, but not limited to, obtaining a credit report from a credit reporting agency, from time to time and for any lawful purposes. Upon the request of an individual owner, officer or guarantor, Ascentium will advise the individual if Ascentium obtained a credit report and Ascentium will give the individual the credit bureau’s name and address. The business-applicant and each owner, officer or guarantor listed above direct any creditor or financial institution having any information relating to the business or individual to release such information to Ascentium in connection with this Application.
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