Equipment Description (including brand)

Total Value (pre-tax) $

Type of Lease: Capital Lease - Conditional Sales Contract - $1 buy out FMV - 10% buy out at end of term

Desired Length of Lease: 24 months 36 months 42 months 48 months 54 months 60 months 66 months

Vendor Information:

Send response to (email address or Fax number):

Equipment Supplier:

Salesperson:

May We Contact You If Any Additional Information Is Required?

Company Information

Full Company Legal Name:

Address:

City:

Prov./State

Postal/Zip:

Phone:

Type of Business:

Business Start Date:

Number of Employees:

Structure: Incorporated        Partnership        Proprietorship

Key Business Contact(s)

Name:

Title:

Address:

City:

Prov. / State:

Postal / Zip:

Phone:

If company for less than 3 years, then:

Date of Birth:

If Proprietorship / Partnership S.I.N #:

Other Principal

Name:

Title:

Address:

City:

Prov. / State:

Postal / Zip:

If company for less than 3 years, then:

Date of Birth:

If Proprietorship / Partnership S.I.N #:

Bank Reference

Bank Name:

Bank Address:

City:

Branch:

Average Balance on Deposit:

Trade Reference

Company Name:

Address:

City:

Nature / Amount of Trade:

Special Notes:

By marking AGREE, the applicant certifies the above information to be true and correct. I/we consent to Qualica Financial Group Inc. obtaining from any credit reporting agency or credit grantor, such information as it may require at any time in connection with the credit hereby applied for, and consent to the disclosure at any time of any information concerning the applicant to any credit reporting agency or to any credit grantor with whom the applicant has financial relations.