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  3. Credit Application

Credit Application

Please complete the following form and * required fields

* Are you a current NEC Lease Customer?     Yes   No
* If yes, Account number
* Legal Name of Applicant
* Address
* City   * State     * Zip   
* Website
* Contact Name   * Email   
* Phone Number      Fax   

Installation address

Installation address is same as company address above (if unchecked the fields below are required).
* Address
* City  * State       * Zip  

Dealer/Vendor Information

* Supplier Name
* Supplier Sales Rep
  Phone Number   Email  

Equipment/Software Information

* Equipment Description
  Equipment Cost
  (exclude tax)
  * Total Cost (exclude tax)  
  Lease Term
24 36 48 60 Other:
  Lease Type
$1 10% FMV Other:
  Lease Payment   Lease Rate Factor  
  Advance Payment(s)    Security Deposit(s)   
  Promotion Code,
  if applicable

Background

  Business Structure/Type    State of Incorporation 
  Years in Business    Federal Tax ID   
* Contact Person Title  
* Phone * Email  
  Lease Signer Title   
  Phone   Email  

Stockholder/Owner 1

  Principal Name
  Home Address
  City   State       Zip  
  Phone   Email  

Stockholder/Owner 2

  Principal Name
  Home Address
  City   State       Zip  
  Phone   Email  

Bank

  Bank Name
  Branch Location
  Account #
  Bank Contact Name   Fax  
  Phone Number   Email