INDUSTRIAL & COMMERCIAL
LEASING COMPANY INC.
32 Foster Road
Pennington, NJ 08534
Ph:
800-922-0432 * FAX 609-818-9777
CUSTOMER
INFORMATION
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Company Name (Full Legal Name of
Business)
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DBA
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Company Street Address
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City / State / Zipcode
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County
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Contact Name / Title
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Phone No.
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Fax Phone No.
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Billing Address (If different from Legal
Address)
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Company Email Address
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Federal Tax ID No.
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Type of Business
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Bus. Begin Year
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State of Registry
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Business Structure
¨ Sole
Proprietorship ¨ General Partnership ¨ Limited
Partnership ¨ Corporation ¨ Sub “S” ¨ LLC
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Equipment Location Street Address
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City / State / Zipcode
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County
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BUSINESS
OWNERSHIP
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Name
/ Title |
Home
Phone No. |
Social
Security No. |
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Home
Street Address |
City
/ State / Zipcode |
%
Ownership |
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Name
/ Title |
Home
Phone No. |
Social
Security No. |
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Home
Street Address |
City
/ State / Zipcode |
%
Ownership |
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List
Others Separately (If Necessary) |
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BANK REFERENCES
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Bank
Name |
Address |
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Account
No. |
Account
Type ¨ Checking ¨ Savings ¨ Borrowing |
Contact
Name |
Contact
Phone No. |
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Bank
Name |
Address |
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Account
No. |
Account
Type ¨ Checking ¨ Savings ¨ Borrowing |
Contact
Name |
Contact
Phone No. |
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TRADE REFERENCES
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Business
Name |
Address |
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Account
No. |
Contact
Name |
Contact
Phone No. |
Contact
Fax Phone No. |
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Business
Name |
Address |
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Account
No. |
Contact
Name |
Contact
Phone No. |
Contact
Fax Phone No. |
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FINANCING REQUEST
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Vendor
Name |
Address |
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Contact
Name |
Email
Address |
Contact
Phone No. |
Contact
Fax Phone No. |
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Type
of Equipment |
Equipment
Status ¨ New ¨ Used |
Equipment
Cost |
Term
(Months) |
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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.