Company Information

· Name: __________________________Yrs. In Business: _____ Type Of Business: ____________
· Address: ________________________City & State: _______________________ Zip: _________
· Phone #: __________________ Fax #: ____________________ E-mail: ___________________

Company Structure

· C-Corp: ___________ S-Corp: ___________ Partnership: ____________ Sole: ___________

Banking Information

· Bank Name: ___________________________________________ Phone# __________________
· Account #: _______________ Type Of Account: ______________ Contact Person: ___________

Trade Information

· Company: ____________________________Company: ________________________________
· Contact: ______________________________Contact: _________________________________
· Phone #: ______________________________Phone #: ________________________________

Ownership Information

· Name: ____________________________ Ownership %: _________ SSN# ____________________
· Home Address: _____________________ City & State: ______________________ Zip: _________
· Name: _____________________________Ownership %: _____ ____SSN# ____________________

· Tentative Equipment: _____________________________________ Cost: $________________
· Requested Term: 24 Mo.___________ 36 Mo.___________ 48 Mo.___________ 60 Mo.__________
I authorize our bank, trade references, and financial institutions to release information by fax to Southern CaliforniaLeasing, Inc. or its Agents. Further, I authorized SCL or its Agents to obtain other credit information including D&B and Credit Bureau Reports.

Signature:_________________________________ Title: _____________________ Date: __________