COMMERCIAL EQUIPMENT LEASE APPLICATION

BUSINESS Information:					                                 
LEGAL NAME OF LESSEE	DBA (IF ANY)	PHONE	
			
ADDRESS (STREET)                                                                                              (CITY)                                                          (COUNTY)                                                           (STATE)                                   (ZIP)	
	
LOCATION OF EQUIPMENT (STREET)                                                             (CITY)                                                          (COUNTY)                                                           (STATE)                                   (ZIP)	
	
TYPE OF BUSINESS	AGE OF BUSINESS		# OF EMPLOYEES	FED’L TAX I.D. #	
	   			   	
(CIRCLE)	(CIRCLE)	
                LANDLORD               MORTGAGEE	               PROPRIETORSHIP            PARTNERSHIP            CORPORATION	
LANDLORD / MORTGAGEE	ADDRESS	CONTACT	PHONE	

OWNERSHIP Information:
PRINCIPAL’S NAME	TITLE	% OWNERSHIP	HOME PHONE	SOC. SEC. #	
					
HOME ADDRESS                                                    (CITY)                                      (STATE)                               (ZIP)	Credit Score	How Long at Address?	Bankruptcy or Liens: Explain	
   				
PRINCIPAL’S NAME	TITLE	% OWNERSHIP	HOME PHONE	SOC. SEC. #	
					
HOME ADDRESS                                                    (CITY)                                      (STATE)                               (ZIP)	Credit Score	How Long at Address?	Bankruptcy or Liens: Explain	

BANK Information:
BANK NAME	ADDRESS                                                      (CITY)                               (STATE)                      (ZIP)	CONTACT	
	   	   	
ACCOUNT NAME	ACCOUNT #                                                                                                      Average Approx. Balance	PHONE	

TRADE Information:
COMPANY NAME	ADDRESS                       (CITY)                  (STATE)              (ZIP)	CONTACT	PHONE	
				
COMPANY NAME	ADDRESS                       (CITY)                  (STATE)              (ZIP)	CONTACT	PHONE	
				
COMPANY NAME	ADDRESS                       (CITY)                  (STATE)              (ZIP)	CONTACT	PHONE	

PURCHASED From:		Dealer_____        Private Seller ______  ( check one)
COMPANY NAME	CONTACT	FAX	PHONE	
				
ADDRESS                                                                                                       (CITY)                                                                               (STATE)                               (ZIP)	FED’L I.D. #	
		
									* must pay 10% of original purchase price upon termination of lease 
EQUIPMENT Information:     Circle:	$ Buyout	FMV	10% PUT* 	Circle:	New   Used (10 years or less)
QUANTITY	EQUIPMENT DESCRIPTION (Type, Make, Model, Year, Serial #):	COST OF EQUIPMENT	    CIRCLE DESIRED # OF MONTHS OF LEASE	

			    12     24    36    48    60	
			    12     24    36    48    60	
				
The undersigned hereby authorizes any bank or other lending institution, creditor, trade, or credit association, or trade or credit reporting bureau, or any other person who has knowledge of Lessee’s credit or trade history to release such information to BRT Financial, Inc. or its assigns or designee(s).  A photographic or faxed copy of this authorization shall be as valid as the original. 

Signed:  									Title: 					

Name:  										Date: 					

BRT Financial, Inc        Phone: 904-551-6090   Fax: 904-513-9229
e-mail: info@brtfinancial.com       website: www.brtfinancial.com