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Main Office
 

 

Commercial Equipment Leasing - Online Application

 

Business / Lessee Information:

 

  
Business (Lessee) Name
Telephone:
Fax:
Address:
City:
State / Zip  
Federal Tax Number:
Business Structure:

Time in business under current ownership:
Business Description:
Pending Legal Action Filed Against Business or Owner?
Contact Name:
Email:
   
Personal Information on Owners
   
Principal's Name:
Title:
% Ownership
Home Phone No.
Social Security Number:
Home Address:
City:
State:
Zip Code:
Own or Rent?
   
Principal's Name:
Title:
% Ownership
Home Phone No.
Social Security Number:
Home Address:
City:
State:
Zip Code:
Own or Rent?
 
 
Has Business or owner filed bankruptcy or assignment to creditors in the past?

Bank Reference
 
Principal Bank:
Contact:
Telephone:
Account under name of:
Checking Account Number:
 
Trade References
 
Company Name-Major Supplier:
Account Number (No COD's):
Telephone:
Contact Person:
 
Company Name-Major Supplier:
Account Number (No COD's):
Telephone:
Contact:
 
Equipment to be Leased
 
Vendor:
Contact:
Telephone:
Fax:
Address:
City:
State / Zip Code  
   
Describe Equipment to be leased:
Purchase Price w/o Tax:
Address of Installation:
Age of Equipment:
Deposit paid to Vendor:
Lease Term Requested
Additional Comments:
 
AUTHORIZATION FOR RELEASE OF INFORMATION
I, or an agent with my permission, completed this application and certify all information is true and accurate.  

I authorize all deposit, borrowing, trade and other financial information to be released to Atlantic Payment Systems LLC (“Atlantic”). I authorize Atlantic (or other funding source designated by Atlantic) to (a) provide information about us and the credit experience of Atlantic (or such other funding source) with us to others, such as banks and credit reporting agencies, and (b) keep this application, whether or not credit is extended.  I acknowledge that, if another individual who is not one of my employees assisted in the preparation of this application, he or she acted as my agent in doing so.  Upon request, Atlantic will tell you whether or not a credit report was requested and, if so, the name and address of the credit reporting agency furnishing the credit report.

 

 (Type in your name to consent to the above authorization terms )
Signature of Owner or Authorized Agent

When complete, click   to send

   

Copyright © 2002-2008 Atlantic Payment Systems, LLC
P.O. Box 9584, Niskayuna, New York 12309-0584
Telephone: 518-346-2115  Fax: 212-658-900
Revised: March 21, 2008