Professional Leasing Source, Inc.

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Lessee Information

Company Name:

DBA (if applicable):

Company Description:

Address:

City:

State:

Zip:

Years In Business:

Office Phone:

Cell Phone:

Email Address:

Federal Tax ID #:

Equipment Information

Equipment Description:

Vendor Name:

Vendor Telephone:

Sales Representative:

Equipment Cost:

Term:

New / Used:

Principal/Owner Information

Principal/Owner 1 Name:

Title:

Social Security Number:

Cell Phone:

Home Address:

City:

State:

Zip:

Date of Birth:

Email Address:

Principal/Owner 2 Name:

Title:

Social Security Number:

Cell Phone:

Home Address:

City:

State:

Zip:

Date of Birth:

Email Address:

I hereby authorize Professional Leasing Source, Inc., its designee, assigns or potential assigns to review his/her personal credit profile provided by national credit bureaus in considering this application and also for the purpose of updating, renewing, extending additional credit or the collection of any late account. I hereby authorize our references to release all credit information. I represent and warrant that the information submitted herein is true, complete and accurate. A facsimile, electronic or other copy of this authorization shall be as valid as the original.

By checking the box below, I agree with the Authorization above and that the information herein is true and correct.

YES