Company Name (Include DBA if different)

    Company Address

      Contact Nme

      Contact Phone

      Contact Title

  Limited Liability Company "S" Corporation Partnership Public Corporation Private Coporation - not sub S Proprietorship Muncipality Non-Profit (501-c-3) Federal Non Governmental Entity   Customer Classification

       Duns Number (if available)

       Tax ID Number

       Time in Business (Date Business Estabblished)

     Business Description

       Equipment Cost

      Equipment Description

     Equipment Dealer

  12 months 24 months 36 months 48 months 60 months   Desired Term

  No Payments Up Front (OAC only) 1 Payment (OAC) 2 Payments (1st and Dep) Select Payment   Advance Payment 

  $1 Purchase Pre-determined % Fair Market Value Trade in (New Purchase)   Purchase Option

  I hereby authorize SA Kohn and/or its agents to verify the information provided with in this application for credit, and authorize references contained to release any necessary information.  If necessary, I/we will provide financial statements, tax returns, or other information as leaserates.com deems necessary.  By submitting this application for credit, I/we warrant that the information is true and correct.  I/we understand that  any credit decision may be reversed if the information contained in this application is found to be incorrect.