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* Note: All fields are required.

Date (MM-DD-YY):  
Sale Rep:  
APPLICATION INFORMATION
Business Legal Name (DBA):  
Billing Address:  
City:  

County:  

State:   Select--------------------- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon NONE OF THE ABOVE

Province (if applicable):  
Country:   --Country-- United States Canada Afghanistan Albania Algeria Andorra Angola Antigua & Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia & Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Cape Verde CentralAfricanRepublic Chad Chile China China-Hong Kong Colombia Comoros Congo Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France FYRO Macedonia Gabon Georgia Germany Ghana Greece Grenada Guatemala Guinea Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgystan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Lucia San Marino São Tomé and Príncipe Saudi Arabia Scotland Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka St Kitts and Nevis Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Gambia Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Western Samoa Yemen Zaire Zambia Zimbabwe Puerto Rico Other
Zip Code:  

Equipment Location: (If other than bill.  
Enter N/A if same as billing)  

Federal ID:  

Nature of Business:  

Type of Organization:   Select ----------- Sole Proprietor LLC Non-Profit Corporation Partnership Age of Business (Current Ownership):  

Contact Name (Full Name)  

Title:  

Email Address:  

Number of Employees:  

OWNERSHIP INFORMATION
Owner 1 Name:  

Title:  

Percentage of Ownership:  

DOB (MM-DD-YY):   SSN:   Home Address (include city, state and zip):  

Home Phone:  

Mobile Phone:  

Owner 2 Name:  

Title:  

Percentage of Ownership:  

DOB (MM-DD-YY):  

SSN:  

Home Address (include city, state and zip):  

Home Phone:  

Mobile Phone:  

BANK & LOAN REFERENCES
Bank Name:  

Contact Person:  

Phone:  

Fax:  

Account Number:  

Bank Name:  

Contact Person:  

Phone:  

Fax:  

Account Number:  

TRADE REFERENCES
Name of Supplier:  

Contact Person:  

Phone:   Fax:   Account Number:   Name of Supplier:  

Contact Person:  

Phone:   Fax:   Account Number:   EQUIPMENT TO BE LEASED

Description/Package:   Equipment Cost (w/shipping):  
ACKNOWLEDGEMENT AND AUTHORIZATION

I hereby certify that the information contained in this application is true and correct. I authorize you or your agents to investigate my/our financial responsibility and creditworthiness. I authorize you to update my/our credit profile from time to time in the future as deemed appropriate. I further authorize any of the above references to verify the information above or provide additional information as requested either by phone, facsimile or e-mail. I/we will be held personally accountable for all the monies due to Rotobrush International LLC and/or it's affiliates.