Equipment Leasing Application

COMPANY INFORMATION (Please list Legal Name. If there is a d/b/a please indicate)

Legal Name of Company :

Business Address :

City : State: Zip:

Billing Address (if different from above)

Address :

City: State: Zip:

Phone: Fax : Cell:

Contact : Website: E-Mail Address :

Time in Business : Yrs Fed Tax ID #: # of Employees:

Nature of the Business : Type of Business :

OWNER DATA (Please indicate all owners with greater than 25% ownership) Attach list if needed

Principal #1 Address :

City/State : Social Security # :

Principal #2 Address :

City/State : Social Security # :

REFERENCES (If you have a Company Reference List, skip this section and attach)

Business Bank : Account #

Bank Contact : Phone: Fax:

1. Trade Reference : Phone :

2. Trade Reference : Phone :

VENDOR'(S) and EQUIPMENT (If more than one Vendor, attach List of Vendor's & Proposals)

Vendor Name : Phone:

Address :

Equipment : Equipment Cost:

Please upload or attach a Vendor Proposal, Invoice or Purchase Order with full description here: (Please attach either .pdf, .zip, .doc., .gif, .jpg, .xls file formats only)

LEASE STRUCTURE (Please enter the lease structure you are requesting)

Lease term in Months: End of Lease Option:

Applicant certifies that all credit and financial information submitted is true and correct. Applicant hereby authorizes First Capital Funding Corporation, its Underwriters and Assigns to investigate Lessee's credit worthiness, and disclose their findings to each other. The Undersigned authorizes all parties contacted to release credit and financial information as part of said investigation. All duplicates of this document are to be viewed as an original.

Signature: Title: Date:

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