INDUSTRIAL & COMMERCIAL LEASING COMPANY INC.

32 Foster Road - Pennington, NJ 08534

PHONE: 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.

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Signature Title Date Signature Title Date