Sharpe Finance Consumer application

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Patient / Consumer Financing Application

Click here to open a one-page, printable and faxable .pdf form. (Acrobat reader is required.)
Patient/Applicant Information
Fields in Bold are Required.
Sharpe Contact:
Procedure Type:
Requested Amount: ($500-$50,000)	.00^† Repayment Term: (months)
	^†You will automatically be considered for the amount requested. Receipt of this amount, however, is contingent upon an adequate level of income and creditworthiness.
First:
Middle:
Last:
Suffix:	(Jr, III, etc.)
Address 1:
Address 2:	(APT,LOT,etc)
City:
State:	ZIP:
Mother's Maiden Name:
E-Mail Address:
Home Phone:	(1231231234) or (123-123-1234)
How Long at Current Address?	(YY) Own/Rent/Other:
Rent/Mortgage Payment: $	.00
Previous Address: (if above is 1 year or less)	(include APT,LOT,etc)
City:
State:	ZIP:
Social Security Number:	Date of Birth: (MM/DD/YYYY)
Drivers License Number:
Drivers License State:
Nearest Relative First Name:
Nearest Relative Last Name :
Nearest Relative Relationship:
Nearest Relative Address :	(include APT,LOT,etc)
Nearest Relative City :
Nearest Relative State:	ZIP:
Nearest Relative Phone Number:	(1231231234)
Name of Current Employer:
Job Type:
Position:
Employer Address:	(include Suite, ,etc)
City:
State:	ZIP:
Business Phone:	(1231231234) or (123-123-1234)
How Long at the Current Employer?:	(YY)
Annual Salary: $	.00 Total Household Income*: $ .00
Other Income**: $	.00 Source:**
	**Alimony, Child Support, or Separate Maintenance income need not be revealed if you do not wish it considered as a basis for repayment.
Previous Employer: (if above is 1 year or less)	Years there: (YY)
Previous Employer Address 1:	(include Suite, etc)
City:
State:	ZIP:

Co-Applicant Information
If there is a co-applicant -
Relationship to Applicant:
First:
Middle:
Last:
Suffix:	(Jr, III, etc.)
Address 1:
Address 2:	(APT,LOT,etc)
City:
State:	ZIP:
*Home Phone:	(1231231234) or (123-123-1234)
How Long at Current Address?	(YY) *Own/Rent/Other:
*Rent/Mortgage Payment: $	.00
Previous Address: (if above is 1 year or less)	(APT,LOT,etc)
City:
State:	ZIP:
Social Security Number:	Date of Birth: (MM/DD/YYYY)
Name of Current Employer:
Job Type:
Position:
Employer Address:	(APT,LOT,etc)
City:
State:	ZIP:
Business Phone:	(1231231234) or (123-123-1234)
How Long at Current Employer?:	(YY)
Annual Salary: $	.00 Total Household Income*: $ .00
Other Income**: $	.00 Source:**
	**Alimony, Child Support, or Separate Maintenance income need not be revealed if you do not wish it considered as a basis for repayment.
Previous Employer: (if above is 1 year or less)	Years there: (YY)
Previous Employer Address 1:	(Include Suite, etc)
City:
State:	ZIP:

Choice of Loan Deferment
Product Type:

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.

Sharpe Equipment Leasing, Inc.
P.O. Box 10337 — Glendale, Az 85318
Phone: (623) 934-1340 — Toll Free: (800) 886-4920 — Fax: (623) 934-9565

© 2002 Sharpe Equipment Leasing, Inc.