CREDIT APPLICATION

 

 

BORROWER/LESSEE INFORMATION

Company Name: Legal Entity (Check appropriate box):
Corporation LLC Partnership Proprietorship
Address:

City: State Zip:

Telephone:

Years in Business:

Federal ID#

PERSONAL INFORMATION OF OWNERS

Name (#1):

Title:

Social Security No.

Home Address:

City: State Zip:

% Ownership:

Home Telephone:

Name (#2):

Title:

Social Security No.

Home Address:

City: State Zip:

% Ownership:

Home Telephone:

EQUIPMENT DESCRIPTION

Distributor/Equipment Supplier:

Contact Name:

Telephone Number:

Equipment Description:

Equipment Cost:

COMPANY INFORMATION

Name of Bank (Primary):

Account No. (Checking):                           Account No. (Loan):

Telephone Number:

Bank Contact:

Name of Bank (Secondary-if applicable):

Account No. (Checking):                           Account No. (Loan):

Telephone Number:

Bank Contact:

PREVIOUS LEASE/LOAN HISTORY

Lender/Lessor (#1):

Telephone #:

Account #:

Original Lease/Loan Amount:

Commencement Date:

Term:

Monthly Payment:

Lender/Lessor (#2):

Telephone #:

Account #:

Original Lease/Loan Amount:

Commencement Date:

Term:

Monthly Payment:

AUTHORIZATION

Authorization Check Box : dated:

By clicking the “Submit Application” box below, I (we) hereby submit an application request to finance or lease equipment through Anthem Capital Group, Inc. or its designee (“Anthem”). As a routine part of Anthem’s business procedures, bank and trade references are requested along with business and personal credit reports. By clicking the “Submit Application” box below, I (we), as the Owner(s) listed above, authorize Anthem to obtain bank references, trade references, business and personal credit reports, along with any other information Anthem requests as part of Anthem’s credit evaluation process. By clicking the “Submit Application” box below, applicant(s) represent(s) and warrant(s) that the information stated above is true and accurate.