Lease Application

	* Required Fields
	PERSONAL INFORMATION OF APPLICANT
	Applicant First and Last Name:*
	Applicant Position at Company:*
	Applicant Mailing Address:*
	City:*
	State and Zip Code:*
	Applicant Home Phone Number:* (Use Format xxx-xxx-xxxx)
	Applicant Work Phone Number: (Use Format xxx-xxx-xxxx)
	Fax Number: (Use Format xxx-xxx-xxxx)
	Applicant Social Security Number:* (Use Format xxx-xx-xxxx)
	Applicant Email Address:
	COMPANY INFORMATION RELEASE
	Legal Name of Company:*
	Type of Ownership:*
	Type of Business:*
	Date of Incorporation (Date Started):* (Use Format xx/xx/xx)
	Company Street Address:*
	Company City:*
	Company State and Zip Code:*
	Company Phone Number:* (Use Format xxx-xxx-xxxx)
	Company Fax Number: (Use Format xxx-xxx-xxxx)
	Federal I.D. Number / EIN / SSN:* (Use Format xxxxxxxxx)
	Company Website Address:
	Email Address:
	BANK REFERENCES
	Name of Bank:*
	Bank Contact First and Last Name:*
	Bank Address:
	Bank Phone Number:* (Use Format xxx-xxx-xxxx)
	Bank Fax Number: (Use Format xxx-xxx-xxxx)
	Primary Checking Account Number:*
	Additional Account Numbers:*
	Average Balance:*
	FORMER BANK IF LESS THAN TWO YEARS
	Name of Bank:*
	Bank Contact First and Last Name:
	Bank Address:
	Bank Phone Number:* (Use Format xxx-xxx-xxxx)
	Bank Fax Number: (Use Format xxx-xxx-xxxx)
	Primary Checking Account Number:*
	Additional Account Numbers:
	Average Balance:*
	TRADE REFERENCE ONE
	Business Name:*
	Contact Name:*
	Mailing Address:*
	Phone Number:* (Use Format xxx-xxx-xxxx)
	Fax Number: (Use Format xxx-xxx-xxxx)
	Email Address:
	TRADE REFERENCE TWO
	Business Name:
	Contact Name:
	Mailing Address:
	Phone Number: (Use Format xxx-xxx-xxxx)
	Fax Number: (Use Format xxx-xxx-xxxx)
	Email Address:
	LEASE INFORMATION
	Amount Requested:*
	Purpose of Lease:*
	Term of Lease:*
	Name of Vendor (If Available):
	Vendor Phone Number (If Available): (Use Format xxx-xxx-xxxx)
	Company Insurance Agent / Broker:
	Agent Phone Number:
	Brief Description of Items Being Leased:

PLEASE READ CAREFULLY

AGREEMENT: The person(s) submitting this form acknowledge(s) and agree(s) that: (1) the information submitted herein is true and correct to the best of my knowledge under penalties of perjury; (2) the equipment will not be used for any illegal or prohibited purpose or use; (3) all statements made in this application are made for the purpose of obtaining a lease as indicated herein; (4) verification of any information contained in the application may be made at any time by Associated Leasing International Corp., its agents, successors and assigns, either directly or through a credit reporting agency, and from any source named in this application. The original copy of this application will be retained by Associated Leasing International Corp., even if the lease is not approved; CERTIFICATION: I/we certify that the information provided in this application is true and correct as of the date set forth electronically below and acknowledge my/our understanding that any intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq. and liability for monetary damages to the lessor, its agents, successors and assigns, insurers and other any person who may suffer any loss due to reliance upon any misrepresentation which I/we have made on this application. I/we hereby give permission for Associated Leasing International Corp. to obtain information contained within my/our credit reports, for the purpose of obtaining a lease.

To Complete Your Application, Click On "I Agree" Below