EXPRESS APPLICATION

Banleaco offers several options for equipment funding. Choose from a variety of options including traditional equipment financing, leasing, and choices on the length of term. And the best part is when you apply during regular business hours we will contact you with a decision in as little as 15 minutes. We understand you are busy and we are committed to making sure you are not waiting for an answer on your financing.

We look forward to being your equipment and software financing partner.

Legal Business Name:

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DBA:

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Business Address:

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City:

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State:

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Zip:

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Phone:

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Email:

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Applicant Name:

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License Type:

DCPTPharm. DOther

Social Security Number:

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Product Information

Product Description:

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Approximate Cost:

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Supplier of Equipment:

Sales Representative:

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I hereby authorize the release of business and/or personal credit information to Banleaco its affiliates or assignees (1) from any source including credit bureau reporting agencies and my bank for the purpose of extending credit, and (2) to any credit reporting agency. Additionally if my application is not approved by Banleaco, I hereby authorize the release of my application without notice, to any other potential lending sources not related to Banleaco for consideration of approval of credit. I hereby represent all information is true, correct and complete. A photo static, facsimile, or other electronic copy of this authorization shall be valid as the original. 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 the applicant has the capacity to enter into a binding contract), because all or a part of the applicant’s income derives from any public assistance programs, or because the applicant has in good faith exercised any rights under the Consumer Credit Protection Act. The federal agency that administers compliance with this law is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580. To help the Government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. This means that when you apply for credit or open an account with Banleaco we will ask for your name, address, date of birth, social security number, and other information that will allow Banleaco to identify you. We may also require that you furnish Banleaco with a copy of your Driver’s License or other identifying documents. Consult your attorney or financial advisor for specific legal and/or tax advice before entering into any type of financing arrangement, and for information on tax deduction eligibility and procedures. BANLEACO AND THE EQUIPMENT VENDOR AND/OR BROKER YOU SELECT ARE SEPARATE COMPANIES, ARE NOT AGENTS OF ONE ANOTHER, AND HAVE NO AUTHORITY TO BIND ONE ANOTHER TO FINANCIAL OR OTHER CONTRACTUAL OBLIGATIONS.

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