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Equipment Leasing Application

Business Information

Business Name/Lessee

Telephone

Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Type of Business

SIC Code

Age of Business

Fed Tax Number

Ownership and Business Structure

Principal Owner's Name (Owner #1)

Title

Ownership %

Home Phone

SSN

Driver's License Number

Do you Rent or Own?

Own

Rent

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Owner #2 Name (if applicable)

Title

Ownership %

Home Phone

SSN

Driver's License Number

Do you Rent or Own?

Own

Rent

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Owner #3 Name (if applicable)

Title

Ownership %

Home Phone

SSN

Driver's License Number

Do you Rent or Own?

Own

Rent

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Equipment to be leased

Vendor

Contact

Telephone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Equipment to be Leased

Cost of Equipment

Terms of Lease

Rate / Monthly Payment

Deposit Received

I hearby authorize any credit bureau or other investigative agency employed by Kellian Business Finance to investigate the references herein listed or statements or other data obtained from me or from any other person pertaining to my credit and other responsibility.

Signature

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Business Information

Ownership and Business Structure

Equipment to be leased

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