1818 N. Taylor St. #354
Little Rock, AR 72207
(501) 375-2822 Office
(501) 375-2551 Fax
Application
Once we receive a completed Application we will have one of our Associates contact you!
 
Contact Information  
 
Business Name DBA
Business Contact Email Address
Business Phone
  Business Fax
  Mobile Phone
Business Address Tax ID
City County State
Zip
 
Business Information  
 
Type of Business Bus. Start Date Yrs w/Current Ownership
Last Yr Annual Sales Current Year-To-Date Sales
 
Exempt From Sales Tax:
Ever Declared Bankruptcy:
Industry Business Structure State of Incorp.
# Owners
Company Website
 
Equipment Summary  
 
Equipment Cost #1 Sales Tax Term Monthly Payment
Vendor Name Vendor Contact Vendor Phone
Vendor Email
Equipment Description
 
Equipment Cost #2 Sales Tax Term Monthly Payment
Vendor Name Vendor Contact Vendor Phone
Vendor Email
Equipment Description
 
Principle Ownership  
 
First Name Last Name Title
Birth Date SSN % of Ownership
Home Address City State
Zip
Home Phone
Mobile Phone
Email
 
Previous Bankruptcy?   Year Own or Rent:
 
Signature
 
Signer: Title: Signed At:
 
By signing below, the undersigned individual, who is either a principal for the credit applicant or a personal guarantor of its obligations, authorizes lessor and/or debtor and their affiliates, successors or its designee (and any assignee or potential assignee thereof) to obtain consumer credit reports relating to his/her individual credit history and/or credit worthiness. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for the purposes of update, renewal or extension of such credit or additional credit for reviewing or collecting the resulting account.

Additionally, I certify that the information contained in this lease application is true and accurate, and in states where permissible, I hereby authorize the filing and recording of UCC Financing Statements showing the Secured Party’s interest in the equipment and grant the Secured Party the right to execute Lessee’s/debtors name hereto. An electronic copy or facsimile copy of this authorization shall be valid as the original.
 
ESignature: Your signature will go here!
 
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 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. The federal agency that administers compliance with this law is the Federal Trade Commission Equal Credit Opportunity, Washington D.C. 20580. If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact Lessor set forth above with 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement.

Notice: To help the government fight the funding of terrorism and money laundering activities, U.S. Federal law requires financial institutions to obtain, verify and record information that identifies each person (individuals or businesses) who opens an account. What this means for you: When you open an account or add any additional service, we will ask you for your name, address and taxpayer ID number that will allow us to identify you. We may also ask to see other identifying documents.