DATE: ___________________

Business Name:				Business Phone: Fax:
Address:			City/State:			Zip:
Federal Tax ID #:		Date Established:			Type Of Business:
Business Structure: Corp	Equipment Location: If Other Than Above

Personal Guarantee(s) of Owners is Required

Guarantor:	Title:		% Owned: %	SSN:
Address:		Telephone No.

Guarantor:	Title:		% Owned: %	SSN:
Address:		Telephone No.

Credit References including Banks, Trades, Leases, Loans and Landlord

(Minimum: Two Years Bank History and a Minimum of three Trade references)

Bank:	Contact:		Ph#:		Fax#:
Bank:	Contact:		Ph#:		Fax#:
Trade:	Contact:		Ph#:		Fax#:
Trade:	Contact:		Ph#:		Fax#:
Trade:	Contact:		Ph#:		Fax#:
Trade:	Contact:		Ph#:		Fax#:
Customer References:		Phone:		Contact:

Equipment and Vendor Information

Vendor:		Telephone:		Fax:
Address:	City:		State:	Zip:

Quantity

Description

Net Cost:

Term:

Comments:

The information contained on this application, together with any accompanying financial statements, schedules or other materials, is submitted to Dick Martin Leasing, Inc for the purpose of obtaining credit and is warranted to be true, correct and complete. The undersigned individual, recognizing that his or her individual credit history may be a factor in the evaluation of the credit of the applicant, hereby consents to and authorizes the above named business credit provider and any assignee, lender or funding service that may 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 they would otherwise have under Fair Credit Reporting Act in the absence of this continuing consent.

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Applicant's Signature:___________________________________

Title:____________________________

Date:________________