620 Washington Avenue, Rensselaer, NY 12144
Phone: 518-463-5557, 800-678-7342 Fax: 518-463-0144
E-mail: www.adirondacklease.com
EQUIPMENT LEASING APPLICATION - Attention: Kevin Islip
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U
B / BUSINESS NAME/LESSEE / TELEPHONE
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I / ADDRESS (STREET) / CITY COUNTY / STATE / ZIP CODE / FAX NUMBER
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E / TYPE OF BUSINESS FEDERAL ID NUMBER / BIZ START DATE / YRS AT THIS LOCATION
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S / LOCATION OF EQUIPMENT (STREET) / CITY / STATE / COUNTY / ZIP CODE
# OF EMPLOYEES ______GROSS SALES $ ______/ BUSINESS CONTACT:
O / Business Structure / CORPORATION PARTNERSHIP PROPRIETORSHIP / Other ______
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N / PRINCIPAL’S NAME / SOCIAL SECURITY # / % OWNERSHIP / YRS. OWNED / TITLE
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R / HOME ADDRESS / (CITY) / (STATE) / ZIP CODE / HOME PHONE NO
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H / PRINCIPAL’S NAME / SOCIAL SECURITY # / % OWNERSHIP / YRS. OWNED / TITLE
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P / HOME ADDRESS / CITY / STATE / ZIP CODE / HOME PHONE NO
B / BANK / ACCOUNT UNDER NAME OF / TELEPHONE / FAX
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N / CONTACT / CHECKING ACCT. NO. / SAVINGS ACCT # / LOAN OR LOC#
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S / BANK / ACCOUNT UNDER NAME OF / TELEPHONE / FAX
CONTACT / CHECKING ACCT. NO. / SAVINGS ACCT # / LOAN OR LOC#
LEASE / LOAN REFERENCES
COMPANY NAME / ACCOUNT NO. / TELEPHONE NO. / ORIGINAL BALANCE
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F
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INSURANCE PROVIDER
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N / AGENCY: / COMPANY: / ACCT #:
S / PHONE : / FAX : / CONTACT:
E / EQUIPMENT TO BE LEASED
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U / VENDOR
V.E. Services, Inc. / Contact
Don Cowan / Telephone Number
888-852-9838
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P / ADDRESS (STREET)
148 North Street
/ CITYNorth Reading
/ STATEMA
/ ZIP CODE01864 / Fax Number
978-664-5439
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E / EQUIPMENT TO BE LEASED
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T / COST OF EQUIPMENT / Amount to Finance / Lease Term / Purchase Option $1 , 10% , FMV
If your application for business credit is denied, you have the right to a written statement of the reason(s) for the denial. This request must be in writing and within 30 days of denial. I verify the accuracy of the above information and authorize the Leasing Company to investigate my credit and banking references.
AUTHORIZED SIGNATURE X ______TITLE:______DATE: ______
AUTHORIZED SIGNATURE X ______TITLE:______DATE: ______