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Vendor Information Form

ACCOUNT INFORMATION

Company Name:
DBA:
Email:
Address:
City:
State:	Select a State 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:
Telephone #:
Fax #:
Fed Tax ID #:
Resale #:
Type of Business:
Years Under Present Ownership:
D & B Rating:
Leasing Coordinator / Contact:
Principle Owner Name:
Home Address:
City:
State:	Select a State 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:
Home Telephone #:
SSN:

PRIMARY COMPANY BANK REFERENCE (2 YR. HISTORY)

Name of Bank/Branch:
Address:
City:
State:	Select a State 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:
Telephone #:
Contact:
Acct #:

PRODUCT LINES (EQUIPMENT TO BE LEASED)

Describe Equipment:
Primary Vendor / Supply Company:
Address:
City:
State:	Select a State 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:
Telephone #:
Contact:
Acct #:

I hereby authorize InteliLease to contact the above named references and to obtain information necessary to verify our financial and service background. I hereby authorize any photocopies of the release to be provided to references above.