INDUSTRIAL & COMMERCIAL LEASING COMPANY INC.

32 Foster Road

Pennington, NJ 08534

Ph: 800-922-0432 * FAX 609-818-9777

CUSTOMER INFORMATION
Company Name (Full Legal Name of Business)					DBA
Company Street Address					City / State / Zipcode				County
Contact Name / Title			Phone No.				Fax Phone No.
Billing Address (If different from Legal Address)
Company Email Address		Federal Tax ID No.			Type of Business	Bus. Begin Year				State of Registry
Business Structure ¨ Sole Proprietorship ¨ General Partnership ¨ Limited Partnership ¨ Corporation ¨ Sub “S” ¨ LLC
Equipment Location Street Address					City / State / Zipcode				County
BUSINESS OWNERSHIP
Name / Title					Home Phone No.			Social Security No.
Home Street Address				City / State / Zipcode					% Ownership
Name / Title					Home Phone No.			Social Security No.
Home Street Address				City / State / Zipcode					% Ownership
List Others Separately (If Necessary)
BANK REFERENCES
Bank Name		Address
Account No.	Account Type ¨ Checking ¨ Savings ¨ Borrowing				Contact Name			Contact Phone No.
Bank Name		Address
Account No.	Account Type ¨ Checking ¨ Savings ¨ Borrowing				Contact Name			Contact Phone No.
TRADE REFERENCES
Business Name		Address
Account No.	Contact Name				Contact Phone No.			Contact Fax Phone No.
Business Name		Address
Account No.	Contact Name				Contact Phone No.			Contact Fax Phone No.
FINANCING REQUEST
Vendor Name		Address
Contact Name	Email Address				Contact Phone No.			Contact Fax Phone No.
Type of Equipment		Equipment Status ¨ New ¨ Used			Equipment Cost			Term (Months)

I/We hereby authorize the release of any and all credit information to Industrial & Commercial Leasing Company Inc. from the above listed references, and certify that all is true and correct to the best of my/our knowledge. The undersigned individual(s), recognizing that his/her/their individual credit histories may be a factor in the evaluation of the credit applicant, hereby consent(s) to and authorize(s) the above named business credit provider to obtain and use a consumer credit report on the undersigned, now and from time to time, as may be needed in the credit evaluation and review process and waives any right or claim they would otherwise have under the Fair Credit Reporting Act in the absence of this continuing consent.

____________________________________________ ____________________________________________

Signature Title Date Signature Title Date

The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against applicants on the basis of race, color, religion, national origin, sex, marital status or age (provided the applicant has the capacity to enter into the 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. If for any reason your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please write to Industrial & Commercial Leasing Company Inc. or call 609 818 9780 within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request of the statement.