LESSEES FULL COMPANY NAME:
EQUIPMENT ADDRESS:
CITY, STATE, ZIP CODE:
BUSINESS PHONE NUMBER:
FAX NUMBER:
CELL PHONE NUMBER:
PAGER NUMBER:
TYPE OF BUSINESS:
FEDERAL ID NUMBER:
DATE BUSINESS STARTED UNDER CURRENT PRESIDENT/OWNER:
D&B NUMBER:
WEB SITE ADDRESS:
EMAIL ADDRESS:

BUSINESS: (choose one)
CORPORATION	LIMITED LIABILITY	PARTNERSHIP	PROPRIETORSHIP

PERSONAL INFORMATION ON OWNER(S) :
NAME :		NAME :
ADDRESS :		ADDRESS :
CITY, STATE, ZIP :		CITY, STATE, ZIP :
SOCIAL SECURITY # :		SOCIAL SECURITY # :
% OF OWNERSHIP & TITLE :		% OF OWNERSHIP & TITLE :

BUSINESS BANK INFORMATION: (LIST ALL ACCT #’S INCLUDING COMMERICAL BORROWING ACCT #’S)
BANK NAME :		BANK NAME :
PHONE # :		PHONE # :
ACCOUNT # :		ACCOUNT # :
CONTACT :		CONTACT :

TRADE REFERENCES : (LIST MAJOR SUPPLIERS YOU HAVE TERMS WITH)
BUS NAME :		PHONE # :
BUS NAME :		PHONE # :
BUS NAME :		PHONE # :

VENDOR & EQUIPMENT INFORMATION : (WHO ARE YOU GETTING THE EQUIPMENT FROM)
BUSINESS NAME :
CONTACT :		PHONE # :
EQUIPMENT :
COST ($) : (WITHOUT TAX)
TERM :		CHECK ONE : NEW	USED/YEAR :

NOTICE TO ALL BUSINESS APPLICANTS: IF YOUR APPLICATION FOR BUSINESS CREDIT IS DENIED, YOU HAVE THE RIGHT TO A WRITTEN STATEMENT OF THE SPECIFIC REASONS FOR DENIAL. TO OBTAIN THE STATEMENT, PLEASE CONTACT FERNWOOD CAPITAL & LEASING, LLC WITHIN 60 DAYS FROM THE DATE YOU ARE NOTIFIED OF OUR DECISION. WE WILL SEND YOU A WRITTEN STATEMENT OF THE REASONS FOR THE DENIAL WITHIN 30 DAYS OF RECEIVING YOUR REQUEST. NOTICE: THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT PROHIBITS CREDITORS FROM DISCRIMINATION AGAINST CREDIT APPLICANTS ON THE BASIS OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, AGE (PROVIDED THE APPLICANT HAS THE CAPACITY TO ENTER INTO A BINDING CONTRACT); BECAUSE, ALL OR PART OF THE APPLICANT'S INCOME DERIVES FROM ANY PUBLIC ASSISTANCE PROGRAM; OR BECAUSE THE APPLICANT HAS IN GOOD FAITH EXERCISED ANY RIGHT UNDER THE CONSUMER CREDIT PROTECTION ACT. THE FEDERAL AGENCY THAT ADMINISTERS COMPLIANCE WITH THIS LAW CONCERNING THIS CREDITOR IS THE FEDERAL TRADE COMMISSION, EQUAL OPPORTUNITY, WASHINGTON, D.C. TO SECURE THIS LEASE, LESSEE AGREES TO PAY TO FERNWOOD CAPITAL THE ADVANCE PAYMENT/SECURITY DEPOSIT REQUIRED AT THE TIME THIS LEASE IS SUBMITTED TO FERNWOOD CAPITAL. IF FOR ANY REASON THIS LEASE IS NOT FINALIZED, IT IS SPECIFICALLY AGREED THAT FERNWOOD CAPITAL MAY RETAIN ADVANCE PAYMENT/SECUTIRY DEPOSIT AND SUCH AMOUNT IS FULLY EARNED BY FERNWOOD CAPITAL.    By signing below, each undersigned individual, as a principal of and/or guarantor for the Applicant, authorizes Lessor, its designees, assignees and potential assignees, to review his or her personal credit profile and other information as provided by national credit bureaus, banks and third parties, as Lessor in its sole discretion shall deem necessary. Such review shall be made for the purpose of considering this Application and for the purpose of any update, renewal or extension of credit to the Applicant or for the collection and review on any resulting accounts with Applicant. A fax or photocopy of this Authorization shall be valid as the original. Typing your name in the 'signature' box verifies adheres you to the same legal bindings as if you had physically signed with a pen and paper. You are bound to the terms listed above. Signature: Date: