Podium Financial - Application

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Application

Please fill out the form below. You can also click the box below to download a PDF application.

Download Application

LESSEE COMPANY INFORMATION

Business Name:
Company Address:
Email:
City:
State:
Zip:
Telephone #:
Fax #:
Tax ID #:
Nature of Business:
Number of Years In Business:

INFORMATION ON OFFICERS, PARTNERS OR GUARANTORS

Principal's Legal Name:
Title:
DOB:
SSN:
% Ownership:
Home Address:
City:
State:
Zip:
How long at this address?
Own home?

Principal 2's Legal Name:
Title:
SSN:
% Ownership:
Home Address:
City:
State:
Zip:
How long at this address?
Own home?

BANK INFORMATION

Account Type:
Account #:
Bank Name
Branch:
Bank Officer:
Telephone #:
Average 6 month balance:

SIGNIFICANT TRADE REFERENCES

Company Name:
Contact:
Telephone #:

Company Name :
Contact:
Telephone #:

Company Name :
Contact:
Telephone #:

EQUIPMENT TO BE LEASED

Equipment Vendor :
Expected Delivery Date (ex: 02/15/06):
Vendor Address:
Vendor City
State:
Vendor Zip:
Telephone #:
Contact Person:
Equipment Cost (ex. $55,000):
Equipment Type:
Desired Lease Term:
Insurance Company:
Agent Name:
Telephone #:

DECLARATION

By submitting this form you certifie that all credit and financial information submitted is true and correct and authorizes Podium Financial Group, Inc, and/or its assignees, to investigate Lessee’s credit worthiness and disclose information and investigation results to each other. The undersigned authorizes all parties contacted to release credit and financial information requested as part of said investigation. All duplicates are to be viewed as valid as the original.