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Leasing Application


 
Click here for the "offline" printable and faxable form. The Flash Plug-in is required.

This form is securely processed through SSL Certification.
Please fill in as much information as possible. Complete applications can be processed faster.

Applicant Information

Sharpe Contact:

Business Name:

Person to Contact:

Street Address:

Suite, etc.:

City:

State:

Zip:

Phone:

Fax:

Email Address:

Type of business:

Medical License #:

Business Start Date:

(mm/dd/yyyy)

Federal Tax ID#:

Resale #:

Legal Structure:

Dealer/Vendor Information

Dealer/Vendor Name:

Contact:

Address:

City:

State:

Zip:

Phone:

Fax:

Email Address:

Location of Equipment

Address, City, State, Zip
(if not the same as the applicant address:)

Officers or Owners (1)

First Name:

Last Name:

% of Ownership:

Title

Home Address:

City:

State:

Zip:

Phone:

SSN:

Officers or Owners (2)

First Name:

Last Name:

% of Ownership:

Title

Home Address:

City:

State:

Zip:

Phone:

SSN:

Officers or Owners (3)

First Name:

Last Name:

% of Ownership:

Title

Home Address:

City:

State:

Zip:

Phone:

SSN:

Bank References (1)

Bank Name:

Account Number:

Bank Contact:

Bank Phone:

Bank Fax:

Type of Account:

Bank References (2)

Bank Name:

Account Number:

Bank Contact:

Bank Phone:

Bank Fax:

Type of Account:

Credit References (1)

Firm Name:

Account Number:

Contact:

Phone:

Fax:

Credit References (2)

Firm Name:

Account Number:

Contact:

Phone:

Fax:

Credit References (3)

Firm Name:

Account Number:

Contact:

Phone:

Fax:

Equipment and Terms

Equipment Description:

Equipment Cost:

(#####.##)

Preferred Lease Term:

Buyout Option:

The above mentioned individual(s), recognizing that his or her individual credit history may be a factor in the evaluation of the applicant, hereby consents to and authorizes the above named business credit provider and any assignee, lender, or funding service that be utilized to obtain and use a consumer credit report on the undersigned, now and from time to time, as may be needed in the credit evaluation and review process and waives any right or claim that they would otherwise have under Fair Credit Reporting Act in the absence of this continuing consent. By clicking the "Send Application" button you agree with this statement.
    

Thank you.

Specials and News

Affiliations: