866.423.7513
Exact Name of Company: FED ID # (If Corporation):
Structure of Company
Corporation Corporation State: L.L.C. L.L.C. State: Proprietorship Partnership
Business open how long?   How long by this owner?   How long at this address?  
Contact Person: Email: Phone: Fax:

Business Address, City, County, State, Zip Code:
Business Description:

Owners/Officers/Partners - Indicate if Jr, Sr, II or III
Name Title Own% Home Address City/State/Zip Home Phone Social Security #

Business Banking References
Branch Officer Phone Account # Chkg Svngs Loan

Other Leases - Active
Leasing Company Contact Phone Account # Equipment Leased

Trade/Supplier Credit References
Reference City, State Phone Contact Account #

Insurance Carrier Providing Coverage
Carrier Agent Phone Address

Equipment Information
Location of Equipment Equipment Description
Vendor: Contact: Address: Phone:
Remarks:
Price of Equipment:   Lease Term (Months):   Purchase Option:  


The undersigned represents that all information provided with this Application is true and correct and hereby authorizes New Line Business Capital, LLC to obtain from third parties, information it deems necessary to arrive at a decision regarding this application. To help fight terrorism and money laundering, the information you provide will be verified. By signing below, the undersigned individual(s) as principle of and/or guarantor for the applicant, authorizes New Line Business Capital, LLC, its designee, assigns or potential assigns, to review his/her personal credit profile provided by a national credit bureau in considering this Application and for the purpose of update, renewal, or extension of credit to the Applicant or the collection of any resultant accounts. The undersigned authorizes all deposit, borrowing, financial and trade information to be released to New Line Business Capital, LLC, its designee, assigns or potential assigns, by telephone or fax. A photocopy or fax of this authorization shall be valid as the original.

By:   Title:   Date:  

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