Lessee Information

Full Business Name

Address

Address2

City

State

---AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

Phone Number

Fax Number

Years in Business

Email

State of Registration

Federal Tax ID#

Business Officers

Principal #1 Name

Principal #1 Title

Principal #1 Ownership (percentage)

Principal #2 Name

Principal #2 Title

Principal #2 Ownership (percentage)

Business Banking Information

Bank Name

Bank Contact Name

Bank Phone

Checking/Savings Account Number

Equipment Information

Equipment Description

Equipment Cost

Term

End of Lease Option (FMV, $1 out)

Vendor Information

Vendor Name

Vendor Email

Vendor Address

Vendor Phone

Vendor Fax

Credit Release Authorization

By signing below, the undersigned, which is either a principal of the applicant or a personal guarantor of its obligations, provides written instruction to Navitas Lease Corp. or its assignee, authorizing review of his or her personal credit bureau and authorizing applicant’s bank and credit references to release credit information on applicant.

Full Name