Full Financing Application If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Lessee (Purchaser) Company Name * DBA Federal Tax ID Address * City, State & Zip * Business Phone Number * Contact Name * Contact Phone Number * Email * Fax Number Business Description Time In Business Under Current Ownership Type of Business S-Corp LLC Proprietorship Partnership Corporation Non-Profit Vendor (Dealer / Seller) Company Name * Address * City, State & Zip * Telephone * Fax Contact Bank References Principal Bank Account Numbers Telephone Contact Personal Information on Officers, Partners or Owners Name * Home Address * City, State & Zip * Telephone * Social Security Number % Ownership E-Signature (Please type your name in all caps.) * Name Home Address City, State & Zip Telephone Social Security Number % Ownership E-Signature (Please type your name in all caps.) New Equipment to be Leased (Attach equipment schedule if necessary) Address of Installation Quantity Model Description Serial Number(s) Purchase Price (Without Tax) Comparable Lending References and Trade References Name Phone Number Contact Person Account Number Name Phone Number Contact Person Account Number Name Phone Number Contact Person Account Number By signing below, the undersigned individual as principal of and/or guarantor for the applicant, authorizes FirstMark Diversified LLC, it’s designee, assigns or potential assigns, to review his/her personal credit profile provided by National Credit Bureaus in considering this application and for the purpose of the update, renewal, or extension of credit to the applicant or the collection of any resultant accounts. A fax or photocopy of this authorization shall be valid as the original Title * Authorizing Officer E-Signature (Please type your name in all caps.) *
