Main - Credit Application

Credit Application
CUSTOMER

Complete name of legal entity. If a corporation, use EXACT registered corporate name.
Company*
DBA
Billing Address

Street Address

Street Address Line 2

CityState

Zip Code
First Name*
Last Name*
Email*
example@example.com
Telephone
Please enter a valid phone number.
Title
Tax ID/EIN
The first two digits can't be 00.
Time in Business Yr(s)
Nature of Business
Type of Business

LLC/LLPProprietorshipPartnershipCorporation

PERSONAL INFORMATION ON OFFICERS, PARTNERS OR GUARANTOR

(Include any person with 20% or more ownership)
Number of Personal Guarantors Listed
Click 'Yes' if the guarantor information is the same as the customer information.

YesNo
First Name*
Middle Name
Last Name*
Title
% Ownership
Email*
example@example.com
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Social Security No*
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
SECOND GUARANTOR

(Include any person with 20% or more ownership)
First Name
Middle Name
Last Name
Title
% Ownership
Email*
example@example.com
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Social Security No
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
THIRD GUARANTOR

(Include any person with 20% or more ownership)
First Name
Middle Name
Last Name
Title
% Ownership
Email*
example@example.com
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Social Security No
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FOURTH GUARANTOR

(Include any person with 20% or more ownership)
First Name
Middle Name
Last Name
Title
% Ownership
Email*
example@example.com
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Social Security No
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FIFTH GUARANTOR

(Include any person with 20% or more ownership)
First Name
Middle Name
Last Name
Title
% Ownership
Email*
example@example.com
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Social Security No
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has the Company or any Guarantors ever declared bankruptcy

YesNo

EQUIPMENT INFORMATION

(Attach separate schedule if necessary)
Attached equipment, invoice, or quote

Cancelof
Quantity
Description (Include make, model & serial #'s and any attachment)
Equipment Cost (excluding applicable tax)
EQUIPMENT SUPPLIER INFORMATION
Supplier's Name
Contact
Email
example@example.com
Telephone Number
Please enter a valid phone number.
REQUEST PAYMENT TERMS

(Attach separate schedule if necessary)
Term in Month
Lease Payment - (not included tax)
Down Payment
Purchase Options

TRADE REFERENCES

Two Year History
Name of Supplier
City/State

Street Address

Street Address Line 2

CityState

Zip Code
First Name
Last Name
Email
example@example.com
Telephone
Please enter a valid phone number.
Are there any additional suppliers?
Name of Supplier
City

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State

Street Address

Street Address Line 2

CityState

Zip Code
Telephone
Please enter a valid phone number.
Email
example@example.com
First Name
Last Name
Name of Supplier
City/State

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Please enter a valid phone number.
Email
example@example.com
First Name
Last Name
COMPANY BANK REFERENCES

Two Year History
Name of Bank/Branch
Checking Account #
Loan Account #
City

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State

Street Address

Street Address Line 2

CityState

Zip Code
First Name
Last Name
Email
example@example.com
Telephone
Please enter a valid phone number.

Signature
Applicant authorizes the release of any credit information concerning applicant including credit reports, loan, lease, checking, saving and trade accounts to Equipment Leasing Group of America, LLC, and / or any of its assigns. Applicant warrants that the information stated above is true and correct. Authorization is granted to use photo, digital, or fax copies of this application and applicant’s signature thereon to obtain credit information.
Guarantor Signature*

Clear
Guarantor Date Signature*

MonthDayYear
Date

Please verify that you are human*
Should be Empty:

Credit Application

CUSTOMER

The first two digits can't be 00.

PERSONAL INFORMATION ON OFFICERS, PARTNERS OR GUARANTOR

SECOND GUARANTOR

THIRD GUARANTOR

FOURTH GUARANTOR

FIFTH GUARANTOR

EQUIPMENT INFORMATION

EQUIPMENT SUPPLIER INFORMATION

REQUEST PAYMENT TERMS

TRADE REFERENCES

COMPANY BANK REFERENCES

Signature