|
VENDOR / DEALER INFORMATION
Vendor's Name
Contact Name
Telephone number
___________________________________|________________________|___________________
Address
Fax-phone number
___________________________________________________________|___________________
City
State
Zip;
E-Mail Address
________________________________________|_____|_____________|___________________
PAYMENT PLAN
(For official use only)
Terms in months
Rate factor used
Lease payment not including taxes;
Options
Security Deposit
______________|________________|___________________|_____________|_______________
EQUIPMENT TO BE LEASED
(Attach separate list if necessary)
Equipment Cost:
Equipment type and description (include make, model, and serial number as well as any attachments)
.
Circle one for notification of Credit decision: Fax or Phone
Circle: New or Used
LESSEE
(Complete Legal name of enitity. If corporation, use EXACT registered corporate name.)
Federal Tax I.D. #:
Company
DBA
___________________________________|________________________|___________________
Billing Address
Street Address (if other
than Billing Address. No P.O. Boxes)
___________________________________|____________________________________________
Nature of Business
Contact person Mr.
OR Mrs.
Title
___________________________________|_________________________|__________________
Telephone #
Type of Business
Proprietorship
Limited Liability Co. No. of Years in Business
Dun & Brad #
Fax-phone #
Corporation
Non-Profit
E-Mail #
Partnership
PERSONAL INFORMATION ON OFFICERS, PARTNERS OR GRANTORS FOR PROPIERTORSHIP REQUIRED
Name
Title
% of Ownership
Social Security No.
______________________________|____________|________________|___________________
Home Address (Physical address. No PO BOxes)
City
State Zip
Home Phone No.
______________________________|___________________|_____|________|_______________
Name
Title
% of Ownership
Social Security No.
______________________________|____________|________________|___________________
Home Address (Physical address. No PO BOxes)
City
State Zip
Home Phone No.
______________________________|___________________|_____|________|_______________
TRADE REFERENCES - TWO YEAR HISTORY
Name of Supplier
City / State / Zip
Telephone No.
Contact Person
______________________________|____________|________________|___________________
Name of Supplier
City / State / Zip
Telephone No.
Contact Person
______________________________|____________|________________|___________________
COMPANY BANK REFERENCES - TWO YEAR HISTORY
Name of Bank / Branch
City / State / Zip
Chkg Acct #
Telephone No.
Contact Person
________________________|_________________|___________|____________|_____________
Name of Bank / Branch
City / State / Zip
Chkg Acct #.
Telephone No.
Contact Person
________________________|_________________|___________|____________|_____________
ACKNOWLEDGEMENT AND AUTHORIZATION
By providing the above information, I/we authorize you or your agents to investigate
my/our financial responsibiity and credit worthliness. I / we authorize you to update my/our credit
profile from time to timein the future as you deem appropriate. I / we authorize my/our bank(s)
and or Trade creditors to release information to American Telemarketing Computers, and/or the
Leasing sources they use, concerning my/our accounts with you. I /we agree that American
Telemarketing Computers, and it's affiliates may share information about me/us and my/our accounts
with affiliates, unless I write to American Telemarketing Computers @ 12443 Lago Vista Dr., Redding, CA
96003
Return Back to
previous page!
Signature_______________________________________________ Date ___________________
|