lease-application

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Lease Application

Business Information
Company Name:
Contact Name:
Contact E-Mail:
Address:
Address (cont):
City, ST, Zip:

DBA:
Fed Tax ID:
Phone:
Business Type:
Year Business Started:
Number of Years Under Current Ownership:
Business Revenue-Last Year End:
Net Income-Last Year Ending:
Net Income Current Year, thru mos
Number of Employees:

Equipment Information
Equipment Type:
Description:
New/Used:	New Used
Age in Months:
Cost:

Vendor Information
Vendor 1:
Vendor Contact:
Vendor 2:
Vendor Contact:

Terms
Term in Months:
Advanced Payment #:
Purchase Option:

Principal 1
First Name:	MI:
Last Name:
Title:
% of Ownership
SSN:
Address:
City, ST, Zip:

Principal 2
First Name:	MI:
Last Name:
Title:
% of Ownership:
SSN:
Address:
City, ST, Zip:

Bank Reference 1
Bank Name:
City:
State:
Phone:
Account Type:
Account Number:
Contact:

Bank Reference 2* (Please provide if Reference 1 above is less than 2 years old)
Bank Name:
City:
State:
Phone:
Account Type:
Account Number:
Contact:

Trade Reference 1
Trade Name:
City:
State:
Phone:
Contact:

Trade Reference 2
Trade Name:
City:
State:
Phone:
Contact:

Trade Reference 3
Trade Name:
City:
State:
Phone:
Contact:

Comments

I/We understand that I/We may submit my application to Southlake Capital electronically by clicking "Click to submit application" below, or I/We may submit the application by fax or mail.

I/We authorize Southlake Capital to make such inquiries regarding the information furnished herein as may be required in connection with the application, or in the course of review of any credit extended in reliance on the application, such as obtaining individual credit bureau reports, Dun & Bradstreet business reports, and/or other credit reports/references. I/We represent that all information set forth in this application is a truthful and accurate representation of facts for the purpose of obtaining the lease financing requested by me/us. If I/We choose to submit this application electronically, I/We acknowledge that Southlake Capital is unable to ensure that the data cannot be intercepted by third parties. In submitting this application electronically I/We knowingly and voluntarily agree that Southlake Capital will not be held liable in any manner whatsoever should such interception occur. I/we understand that other financial information may be requested in connection with this lease application, and that this application is not an offer to extend credit.

Do you agree and accept? Yes No

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