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BLC Representative Name
CLIENT
(Complete legal name of entity. If a corporation, use EXACT registered corporate name.)
Company*
DBA (If applicable)
Billing Address*
Street Address Address Line 2 City State ZIP / Postal Code
Phone Number*
Fax Number
Contact Person*
First Last
Nature of Business*
FED ID#
Number of Years in Business*
Please enter a number less than or equal to 700.
EQUIPMENT/ASSET TO BE FINANCED
Description*
(Include Make, Model, and Serial #'s and any attachment)
Equipment Cost*
Payment Frequency*
- Monthly
- Quarterly
- Semi - annually
- Annual
- Other
How Often Will You Make Payments?*
VENDOR INFORMATION
Vendor's Name
Contact
First Last
Phone Number
PERSONAL INFORMATION ON OFFICERS, PARTNERS, OR GUARANTORS
Name*
First Last
Home Address
Street Address Address Line 2 City State ZIP / Postal Code
Phone
Social Security Number*
Email
Date of Birth
MM slash DD slash YYYY
Percent of Ownership
AUTHORIZATION FOR RELEASE OF CREDIT AND OR BANK INFORMATION

All information in this application and all attachments is correct to the best of my knowledge. I authorize verification of employment and all financial and other information submitted with this application, including obtaining a credit report, to act on this application. I authorize making continued inquiries about such information and obtaining a credit report during the term of my lease(s) as necessary to administer my lease(s). As required by law, my identity will be verified. I authorize all past or present creditors to release any and all necessary credit information, and to respond fully to requests for information based on this application when transmitted by electronic or other means. I authorize any lessor making a lease applied for hereby to disclose to you, on a confidential basis, my personal credit and other information (including without limitation post-closing information regarding the servicing of the lease and any defaults thereunder), whether or not you are a servicer of the lease. The above permissions and authorizations will apply to any creditor to whom this application is submitted. I certify that the lease(s) applied for hereunder are for business, commercial or agricultural purposes and not for personal, family or household purposes
Consent*
I agree to the Terms and Conditions
All information in this application and all attachments is correct to the best of my knowledge. I authorize verification of employment and all financial and other information submitted with this application, including obtaining a credit report, to act on this application. I authorize making continued inquiries about such information and obtaining a credit report during the term of my lease(s) as necessary to administer my lease(s). As required by law, my identity will be verified. I authorize all past or present creditors to release any and all necessary credit information, and to respond fully to requests for information based on this application when transmitted by electronic or other means. I authorize any lessor making a lease applied for hereby to disclose to you, on a confidential basis, my personal credit and other information (including without limitation post-closing information regarding the servicing of the lease and any defaults thereunder), whether or not you are a servicer of the lease. The above permissions and authorizations will apply to any creditor to whom this application is submitted. I certify that the lease(s) applied for hereunder are for business, commercial or agricultural purposes and not for personal, family or household purposes.

The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. A number of federal agencies share enforcement responsibility for this law. Determining which agency to contact depends on the type of creditor you dealt with. Consult the creditor to whom this application is addressed for information on its regulator, or contact The Federal Trade Commission, Consumer Response Center, Washington, D.C. 20580, 1-877-382-4357.
Digital Signature*
First Last
Signature*
Date*
MM slash DD slash YYYY
The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. A number of federal agencies share enforcement responsibility for this law. Determining which agency to contact depends on the type of creditor you dealt with. Consult the creditor to whom this application is addressed for information on its regulator, or contact The Federal Trade Commission, Consumer Response Center, Washington, D.C. 20580, 1-877-382-4357.

61590

Ready to begin?

Apply now!

Securely process your information:

CLIENT

EQUIPMENT/ASSET TO BE FINANCED

VENDOR INFORMATION

PERSONAL INFORMATION ON OFFICERS, PARTNERS, OR GUARANTORS

AUTHORIZATION FOR RELEASE OF CREDIT AND OR BANK INFORMATION

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