Freedom Financial Leasing Corporation

COMPANY INFORMATION
Business Name*:
Business Address*:
City*:
State*:
Zip Code*:
Tax ID Number:
Business Phone*:
Business Fax:
E-Mail*:
Years in Business*:
Type of Business*:
BANK REFERENCE 1
Bank*:
Bank Phone*:
Bank Contact*:
Bank Account #:
BANK REFERENCE 2
Bank:
Bank Phone:
Bank Contact:
Bank Account #:
TRADE REFERENCE 1
Company*:
Company Phone*:
Company Contact*:
Company Account #:
TRADE REFERENCE 2
Company*:
Company Phone*:
Company Contact*:
Company Account #:
TRADE REFERENCE 3
Company:
Company Phone:
Company Contact:
Company Account #:
OWNERSHIP & PRINCIPAL INFORMATION 1
Name*:
Title*:
Ownership (%)*:
Home Address*:
City*:
State*:
Zip*:
Home Phone*:
Social Security #*:
OWNERSHIP & PRINCIPAL INFORMATION 2
Name:
Title:
Ownership (%):
Home Address:
City:
State:
Zip:
Home Phone:
Social Security #:
VENDOR/SUPPLIER INFORMATION
Vendor Name:
Vendor Contact:
Vendor Phone:
*EQUIPMENT DESCRIPTION:**

Amount Requested*:$
Term:
Purchase Option:
COMMENTS:

My checking this box will serve as authorization to release information regarding my account(s) to Freedom Financial Leasing Corporation.