Access Leasing Services, Inc.

P.O. Box 261

Cohasset, Ma. 02025

Tel. 1-781-383-8876 Fax 1-781-383-8875

EQUIPMENT LEASING APPLICATION

V E N D O R	^VENDOR			^CONTACT
	^ADDRESS (STREET) (CITY) (STATE) (ZIP CODE)			^TELEPHONE
	^EQUIPMENT TO BE LEASED^o^NEW^o^USED^o^AGE FAX NO.
	^COST OF EQUIPMENT	^TERMS OF LEASE	^RATE/MO. PAYMENT	^DEPOSIT RECEIVED

L E S S E E	^BUSINESS NAME/LESSEE	^TELEPHONE
	^ADDRESS (STREET) (CITY) (STATE) (COUNTRY) (ZIP CODE)
	^SIGNER^TYPE OF BUSINESS		^Yrs in bus.	^FED. TAX NO.
	^LOCATION OF EQUIPMENT (STREET) (CITY) (STATE) (COUNTRY) (ZIP CODE)

G U A R A N T O R S	^Business Structure^o^Corp.^o^Proprietorship^o^Partnership^o^Non-Profit
	^PRICIPAL'S NAME	^TITLE	^% OWNERSHIP	^HOME PHONE NO.	^SOC. SEC. NO.
	^ADDRESS (STREET) (CITY) (STATE) (ZIP CODE)			^o^OWN^o^RENT	^DRIVER'S LIC. NO
	^PRICIPAL'S NAME	^TITLE	^% OWNERSHIP	^HOME PHONE NO.	^SOC. SEC. NO.
	^ADDRESS (STREET) (CITY) (STATE) (ZIP CODE)			^o^OWN^o^RENT	^DRIVER'S LIC. NO
	^PRICIPAL'S NAME	^TITLE	^% OWNERSHIP	^HOME PHONE NO.	^SOC. SEC. NO.
	^ADDRESS (STREET) (CITY) (STATE) (ZIP CODE)			^o^OWN^o^RENT	^DRIVER'S LIC. NO

B A N K S	^BANK	^BRANCH		^FAX		^TELEPHONE
	^ACCOUNT UNDER NAME OF	^CHECKING ACCT. NO.	^LOAN ACCOUNT			^CONTACT
	^BANK	^BRANCH			^FAX	^TELEPHONE
	^ACCOUNT UNDER NAME OF	^CHECKING ACCT. NO.	^LOAN ACCOUNT			^CONTACT

T R A D E S	^COMPANY NAME	^ACCOUNT NO.	^TELEPHONE NO.	^CONTACT PERSON
I hereby authorize Access Leasing, Inc. or any credit bureau or other investigative agency employed by Access leasing to investigate the references herein listed or statements or other data obtained from me or from any other person pertaining to my credit and financial responsibility ____________________ SIGNATURE ________________________________________________________ DATE

FAX THIS APPLICATION TO 1-877-525-5551