Lessee's Full Legal  Name:                                                    Lessee Phone #____________________

___________________________________________                     Fax #____________________

Nature of Business: ___________________________   Yrs in Practice: ____  License #__________

Type:    ___Sole Prop.      ___Partnership       ___Corp - State of Incorporation ______________

Business Address (City, State, County & Zip Code):

______________________________________________________________________________

Owners Name: ________________________________     Social Security #: ___________________

Home Address (City, State, Zip):______________________________________________________

Owners Name: ________________________________     Social Security #: ___________________

Home Address (City, State, Zip):______________________________________________________

Bank name: _____________________________   Account #:_______________________________

Branch Phone # __________________________  Bank Contact: ____________________________

If equipment cost is >$15k list trade references:

1)  _____________________________________________  Phone # ____________________

2)  _____________________________________________  Phone # ____________________

3)  _____________________________________________  Phone # ____________________

Equipment: _______________________________________________________________________

Term of Lease:  24    36    48     60             Purchase Option:     $1.00        10%

Equipment Cost: $_____________                I/we hereby authorize the lessor or its assigns to acquire from any reporting agency,
               Other: $_____________                 consumer or commercial, or any bank, trade reference, or other institution any credit
           Shipping: $_____________                information pertaining to us or the business referenced above that they may require
                            .                                          for  the purpose of making a credit decision or the collateral of any resulting account.
                 Total: $_____________

                                                                    Signature _____________________     Date __________