1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21  
- 21 -

C & W Leasing

658 South Military Trail
Deerfield Beach, Florida 33442
(954) 725-0425
(954) 725-3325 Fax
(800) 949-0018 Ext. 205

Lease application

Contact: Brenda Liner
Fax: (954) 725-3325

VENDOR IMFORMATION
Vendor Name
Vendor Address
Contact Person Telephone Number
LESSEE COMPANY INFORMATION
Company Name
Company Address City Country State Zip
Signer   Title Telephone Number
Nature of Business Type of Business No. of Years in Business
_ Non-Profit _ Proprietorship _ Partnership _ Corporation

Quote

Initial Term                   ___________
Equipment cost          $ __________
x Rate Factor                ___________
Base Periodic Lease
Payment                      $___________
(Transfer amount to Lease Agreement)

# of Pmts. Required
as a Security Deposit  _________
Security Deposit       $_________

(Check for this amount to accompany Lease)
Equipment Description  _____________
______________________________________
______________________________________
______________________________________

PERSONAL INFORMATION ON OFFICERS PARTNERS OR GUARANTORS
Name Title Social Security Number Driver's License Number
Home address City State Zip How Long? Home Phone Number
Previous address City State Zip Own / Rent Present Home?
Name Title Social Security Number Driver's License Number
Home address City State Zip How Long? Home Phone Number
Previous address City State Zip Own / Rent Present Home?
COMPANY BANK REFERENCES . TWO YEAR HISTORY
Name of Bank/Branch How Long? Chkg. Acct. #
Laon Acct. #
Telephone No.
(           )
Contact Officer
Name of Bank/Branch How Long? Chkg. Acct. #
Laon Acct. #
Telephone No.
(           )
Contact Officer
Name of Bank/Branch How Long? Chkg. Acct. #
Laon Acct. #
Telephone No.
(           )
Contact Officer
TRADE REFERENCES . TWO YEAR HISTORY
Name of Supplier City/State Telephone No.
(           )
Contact Officer
Name of Supplier City/State Telephone No.
(           )
Contact Officer
Name of Supplier City/State Telephone No.
(           )
Contact Officer
LANDLORD INFORMATION
Landlord City/State Telephone No.
(           )
Contact Officer
Landlord City/State Telephone No.
(           )
Contact Officer
Landlord City/State Telephone No.
(           )
Contact Officer
|/we hereby authorize you to whom this application is made, or your agents, to investigate my/our credit worthiness and will provide financial statements, tax returns. etc., as you deem necessary. |/we agree that the security deposit is not refundable unless the application is rejected by Lessor. By the execution of the lease agreement, |/we warrant that the information submitted herein is true and correct and hereby authorized references contained herein to release any necessary information. Further, |/we warrant it is understood that Lessor reserves the right to reserve any credit decision if the information contained herein is found to be incorrect, and |/we will indemnify Lessor for any and all costs incurred with this application for credit including any cost incurred in the placement or reservation of the intended leased equipment based on the information contained herein.

Signature
x

Date: