Application for Equipment Financing

Business Information

Name

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Address

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City

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Zipcode

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Phone Number

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Fax

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Contact First Name

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Title

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Cell Number

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Contact Last Name

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E-mail Address

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Tax I.D. Number

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Corporation

Partnership

LLC

Proprietorship

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Years in Business

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Date Incorporated

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Equipment Description (if you have a sales quote or invoice from the supplier, please fax it along with this application)

Equipment Description

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Owner Information

Personal Credit - Officers/Partners

Name (1)

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Address

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City

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Zipcode

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Home Phone Number

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Social Security Number

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Name (2)

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Address

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City

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Zipcode

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Home Phone Number

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Social Security Number

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Signatures

Applicant hereby authorizes the release of credit information to our company, or its designee (and any assignee or potential assignee thereof) from any source including credit bureau reporting agencies and applicant’s bank. If Personal information is provided, by signing below, the undersigned individual(s), provides written instruction to our Univest Capital, Inc., or its designee (and any assignee or potential assignee thereof) authorizing review of his/her personal credit profile from a national credit bureau. I hereby represent that all of the information contained in this credit application is true, correct and complete.

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Signature (1)

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Print Name

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Date

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Signature (2)

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Print Name

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Date

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The signer(s) acknowledge(s) and understand that our company is relying on this information provided herein in deciding to grant or continue credit or to accept a guarantee thereof. Each of the signers represents, warrants and certifies that the information provided herein is true, correct and complete and agrees to notify our company immediately of any changes to this information. NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract): because all or part of the applicant’s income derives from any public assistance program: or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Federal Reserve Consumer Help Center, PO Box 1200, Minneapolis, MN 55480.

<p style="font-size: 16px; line-height: 1.2em; padding-bottom: 35px;">The signer(s) acknowledge(s) and understand that our company is relying on this information provided herein in deciding to grant or continue credit or to accept a guarantee thereof. Each of the signers represents, warrants and certifies that the information provided herein is true, correct and complete and agrees to notify our company immediately of any changes to this information. <b>NOTICE:</b> The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract): because all or part of the applicant’s income derives from any public assistance program: or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Federal Reserve Consumer Help Center, PO Box 1200, Minneapolis, MN 55480.</p>

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