COMPANY INFORMATION
Legal Business Name:
Your E-mail Address:
DBA:		Phone:		Fax:
Address (street, city, state, zip):
Equipment Location (if different than above):
Authorized Officer/Signor: Title:
Nature of Business:			Yrs. in Business (present ownership):
Type of Business: Proprietorship Partnership Corporation					State:

OWNERSHIP / OFFICER / GUARANTOR INFORMATION
Name (1): Title: Ownership (%):
Home Address (street, city, state, zip):
Own Rent		Social Security No:
Name (2): Title: Ownership (%):
Home Address (street, city, state, zip):
Own Rent		Social Security No:

COMPANY BANK REFERENCES
Bank Name (1):		Phone:		Contact:
Account No:		Acct. Type: Checking Savings Other
Bank Name (2):		Phone:		Contact:
Account No:		Acct. Type: Checking Savings Other

COMPANY TRADE CREDIT REFERENCES (include any lease references)
Company Name	Account No.	Phone No.	Contact

VENDOR / EQUIPMENT TO BE LEASED
Vendor:		Phone:		Fax:
Address (street, city, state, zip):				Contact:
Description:
Equipment Cost:		Lease Term:		Residual:

I/We hereby authorize Premier Leasing Services, or your agents, to investigate my/our credit worthiness. I/We further authorize release of any credit/financial information pertaining to above accounts to Premier Leasing Services, or it's assigns. I/We represent and warrant that the information submitted herein is true and correct.