Unified Lease Application

Applicant Information
Business Name
Business Type*

CorporationLLCSole ProprietorNon-ProfitState/Local Government
Tax ID or EIN*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail*
Have You Ever Filed For Bankruptcy?*

YesNo
Principal's Name

First NameLast Name
Social Security Number*
Home Phone

Area CodePhone Number
Date of Birth*

MonthDayYear
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Equipment to Lease
Equipment to Lease*
Estimated Cost
Estimated Cost*
Lease Term
Acknowledgement and Authorization

Customer warrants that all information in this application is accurate, true, and complete and agrees to notify our company immediately of any changes to this information. The person signing below, as an individual and as an authorized representative of the customer authorizes any credit reporting agency, or other third party to collect and release any credit information concerning the above named company or principal (including consumer credit reports) to the lender chosen by Texas Media Systems, that lender’s affiliates and their respective designees or assignees. Customer agrees that equipment leased from that lender will be used solely for business or commercial purposes. Customer agrees that a facsimile copy of this Agreement shall be deemed an original, and will be treated as an original for all purposes.
Signature*
All fields required. "Submit" button will not appear until all fields are complete.
How Did You Hear About Us?*
How Did You Hear About Us?*
Who Referred You?*
Please Explain:*
Should be Empty:

Applicant Information

Equipment to Lease