(800) US MONEY /  Fax (713) 460.1364
Leasing Division        

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PLEASE COMPLETE THE APPLICATION AND SUBMIT FOR REVIEW.

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Business Information

  
  Complete Legal Business Name:
  Business Structure
  Any Other Businesses Owned?
  How Many?
  Annual Sales Of Business: $
  Number Of Years In Business: years    months
  Federal Tax ID Number:
  Number Of Employees:

Location Of Business

  
  Address:
  City:    
  County: Zip Code:

Location Of Equipment to Finance

  Address:
  City:    
  County: Zip Code:

Contact Information

 
  Phone Number:    Alternate:
  Fax Number:
  Person To Contact:
  Email Address To Expedite Request:

Authorizing Officer 1

  Authorizing Officer - Name:
  Authorizing Officer - Title:
  Social Security:
  % Owned %
  Phone Number:   
  Home Address:
  City:    
  County: Zip Code:

Authorizing Officer 2

  Authorizing Officer - Name:
  Authorizing Officer - Title:
  Social Security:
  % Owned %
  Phone Number:   
  Home Address:
  City:    
  County: Zip Code:

Banking Information

  Bank Name:
  Business Account Number:
  Average Balance: $
  Contact Name:
  Phone Number:   
 

Sales Order Details
  Please Briefly Describe What We Are Financing:

YOUR COMPANY NAME HERE

  Sales Representative's Name:
  Phone Number:   
  Total Cost Of Order: $
  Finance Term In Months:
  Approximate TOTAL Monthly Payment Quoted: $
 
THE UNDERSIGNED ACKNOWLEDGES THAT AMERISOURCE LEASING SERVICES, LLC AND ITS ASSIGNEES WILL BE REVIEWING OUR BUSINESS CREDIT PROFILE INCLUDING OUR PERSONAL CREDIT BUREAU REPORTS AND BY SUBMITTING THIS APPLICATION FORM GAINS OUR PERMISSION TO DO SO.