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INTELILEASE REPRESENTATIVE
(leave blank if you don't have one)
Representative Name:
LESSEE COMPANY INFORMATION
*
Company Name:
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Signer:
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Company Address:
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Title:
*
Email:
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Telephone #
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City:
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Fax #
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State:
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*
State Corp. Filing #
*
Zip:
*
Years In Business:
*
Type of Business:
*
Number of Employees:
INFORMATION ON OFFICERS, PARTNERS OR GUARANTORS
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Name:
Name:
*
Title:
Title:
*
SSN:
SSN:
*
% Ownership:
% Ownership:
*
Home Address:
Home Address:
*
City:
City:
*
State:
Choose One
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Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State:
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Flordia
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip:
Zip:
BANK REFERENCES - FIVE YEAR HISTORY
Bank Reference #1
Bank Reference #2
*
Bank/Branch:
Bank/Branch:
*
How Long?
How Long?
*
Chkg Acct. #
Chkg Acct. #
*
Telephone #
Telephone #
*
Contact Officer:
Contact Officer:
TRADE REFERENCES - TWO YEAR HISTORY
Trade Reference #1
Trade Reference #2
*
Supplier:
*
Supplier:
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City:
*
City:
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State:
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Alaska
Arizona
Arkansas
California
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Connecticut
District of Columbia
Delaware
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Georgia
Hawaii
Iowa
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Indiana
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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State:
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Flordia
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Telephone #
*
Telephone #
*
Contact Person:
*
Contact Person:
LEASE/LOAN REFERENCES
Lease/Loan Reference #1
*
Lessor/Bank:
Lessor/Bank:
*
City:
City:
*
State:
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Flordia
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State:
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Flordia
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Telephone #
Telephone #
*
Contact Person:
Contact Person:
EQUIPMENT DESCRIPTION (MAKE, MODEL, YEAR)
*
Description:
EQUIPMENT COST
*
Cost:
DECLARATION
The above information, together with any accompanying financial statements, schedules, or other materials, is submitted for the purpose of obtaining credit and is warranted to be true, correct and complete. The undersigned hereby warrants that any individual identified above who is either a principal, a personal guarantor or a sole proprietor of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, has provided his/her written authorization for inquiry into their credit worthiness, including but not limited to obtaining a consumer credit report, and shall hold InteliLease and its assignees, agents or nominees harmless from same. You understand that such investigation may include seeking information as to the background, credit and financial responsibility of your officers and principals (or any of them). The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status or age (provided the applicant has the capacity to enter into the binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. If for any reason your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please write to InteliLease 30101 Agoura Ct. #122, Agoura Hills, CA 91301 within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial of credit within 30 days of receiving your request for the statement.
I hereby authorize the release of any credit information to the lessor, its assigns, its designees, assigns or potential assigns
(check box to agree)
InteliLease
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30101 Agoura Ct. #222
•
Agoura Hills, CA 91301
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Phone: (866) 946-8689
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Fax: (480) 247-5638
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info@intelilease.com