1. VENDOR NO. 4054 VENDOR NAME ABC Company LLC
PHONE: 317-573-9061 CONTACT PERSON: Jack Barron
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2. LESSEE Phone No. _______________________________
LESSEE COMPANY NAME______________________________________________________________________________
Company Address ________________________________________________________________________________
Street City (County) State Zip
Type of Business
________________________________________
Proprietor
*Partnership
Corporation
D&B Rating ______________ Years in Business _______ *If Partnership, names of all general partners & Home
address to be obtained
INDIVIDUAL OR PRINCIPAL _____________________________ TITLE ___________________________________
Home Address ________________________________________ SS No.____________________________________
______________________________________________________ Home No. _______________________________
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3. BANK Reference(s)
A. _____________________________________________________________________________________________________
Name of Bank Branch Acct# Contact Phone No.
B. _____________________________________________________________________________________________________
Name of Bank Branch Acct# Contact Phone No.
TRADE Reference(s)
A. _____________________________________________________________________________________________________
Supplier Name Acct# Contact Phone No.
B. _____________________________________________________________________________________________________
Supplier Name Acct# Contact Phone No.
4. EQUIPMENT TO BE LEASED COST
No. of Units ________________________________ Equipment $________________________
Manufacturer ________________________________ Freight $________________________
Model No. ________________________________ Installation $________________________
Attachments ________________________________ Taxes $________________________
New
Used
TOTAL COST $
__________________________
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5. LEASE TERM _____________ PAYMENT QUOTED ________________ PURCHASE OPTION _______________
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6. EQUIPMENT LOCATION: If equipment will be located at different address:
_______________________________________________________________________________________________________________
Street City (County) State Zip
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7. APPROVAL: I hereby authorize you to whom the application is made, or any credit bureau or other investigative agency employed by such
person, 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. Dolphin Capital is hereby authorized to prepare formal documents as per the terms and conditions set forth above.
Name ___________________________________________ Signature_______________________________________
Please Print
Date ___________________________________________ Title ______________________________________