Online Credit Application

Lessee (Complete Legal Name of Entity):

• * Company Name:
• * Address:
• * City:
• * State:
• * Zip:
• * Phone:
• * Email:
• * Medical Specialty:
• * Years in Business:
• * Years Licensed:
• Federal ID Number:

Ownership

Owner 1

• * Name:
• * Title:
• * Address:
• * City:
• * State:
• * Zip:
• * Social Security #:
• * % Ownership:

Owner 2

• Name:
• Title:
• Address:
• City:
• State:
• Zip:
• Social Security #:
• % Ownership:

Equipment Information

* Equipment Description:

* Total Equipment Cost ($):

* Lease Term Requested: 24 Months 36 Months 48 Months 60 Months

Deferred Payment: Yes No

End of Term Buyout Option: $1.00 10% Fair Market Value

Vendor Information

• * Vendor:
• * Phone:

Bank References

• Bank Name:
• Phone:
• Account Number:
• Contact Person:

Credit Information Release

I/We understand that I/We may submit my application to Chase Industries electronically by clicking "Submit Application" below, or I/We may submit the application by fax or mail. I/We authorize you to make such inquiries regarding the information furnished herein as may be required in connection with the application or in the course of review of any credit extended in reliance on the application. All information set forth in this application is a truthful and accurate representation of facts for the purpose of obtaining the lease financing requested by me/us. If I/We choose to submit this application electronically, I/We acknowledge that Chase Industries is unable to ensure that the data cannot be intercepted by third parties. In submitting this application electronically I/We knowingly and voluntarily agree that Chase Industries will not be held liable in any manner whatsoever should such interception occur. I/we understand that other financial information may be requested in connection with this lease application.

The undersigned individual, recognizing that his or her individual credit history may be a factor in the evaluation of the credit of the applicant, hereby consists to and authorizes Chase Industries and any assignee, lender or funding service that may be utilized 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 waivers any right or claim they would otherwise have under Fair Credit Reporting Act in the absence of this continuing consent. I also authorize the above bank reference to release any information that may be requested by Chase Industries or its affiliates/partners.

* Credit Release Authorization: Yes No

Please Enter the Code Below.

Reload Image