Phone:	708-316-5000
Fax:	708-316-5050

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Lessee Information
Corporate Name:
dba:
Company Address:
Company City:
Company State:
Company Zip:
Company Phone:		required
Company Fax:
Years in business		required
Company Ttype:
Federal Tax id#:


Principle Ownership Information
Name:		required
Home Phone:		required
Address:		required
City:		required
State:		required
Zip:		required
SSN:		required
Name:		required
Home Phone:		required
Address:		required
City:		required
State:		required
Zip:		required
SSN:		required


Company Bank Information
Business Bank Name:		required
Checking Account#:
Bank Phone Number:


Supplier References

Company Name:
Phone:
Contact Name:
Amount Requested:		required
Term:
Type of Equipment:		required

This application submitted electronically shall have the same force and effect as if the application bore an inked original signature(s). The above information, together with any accompanying financial statements, schedules, or other materials, is submitted for the purpose of obtaining credit and is warranted to be true, correct and complete. The undersigned hereby warrants that any individual identified above who is either a principle, a personal guarantor or a sole proprietor of the credit applicant, recognizing that his or her individual credit history may be a factoring the evaluation of the credit history of the applicant, has provided his/her written authorization for inquiry into their credit worthiness, including but not limited to obtaining a consumer credit report, and shall hold Continental Financial and its assignees, agents or nominees harmless from the same. You understand that such investigation may include seeking information as to the background, credit, and financial responsibility of your officers and principles (or any of them).
	I accept

Continental Financial
2600 S. 25th Avenue
2nd Floor / North
Broadview, IL. 60155

Phone: 708-316-5000
Fax: 708-316-5050

©2007 Continental Financial