Personal Information

Individual Or Firm Name:

First:

Last:

Date:

Street Address:

Address 2:

City:

State/Province/Region:

Zip/Postal Code:

Country:

Cell Phone:

Business Phone:

Email:

Federal Tax ID:

Business Type:

Business Information

Principal Or Officer:

Social Security No.

Title

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Principal or Officer:

 Enter another Principal or Officer if applicable

Social Security No.

Title:

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Principal or Officer:

  Enter another Principal or Officer if applicable

Social Security No.

Title

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Bank Information

Bank Name:

Account Number:

Phone:

Bank Contact:

 Trade References

First Name:

Last Name:

 Street Address:

Address 2:

City:

State/Province/Region:

Zip/Postal Code:

Country:

Cell Phone:

Business Phone:

Email:

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  First Name:

Last Name:

  Street Address:

Address 2:

City:

State/Province/Region:

Zip/Postal Code:

Country:

Cell Phone:

Business Phone:

Email:

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  First Name:

Last Name:

  Street Address:

Address 2:

City:

State/Province/Region:

Zip/Postal Code:

Country:

Cell Phone:

Business Phone:

Email:

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Equipment

Type of Equipment

Least Terms Desired

Total Cost

Signature

  The undersigned individual/s as principal of and/or guarantor for the applicant provides written consent to Legacy Finance Group, LLC and/or assigns or potential assigns authorizing review of his or her Personal Credit profile from a National Credit Bureau and review of bank account and Trade information now and from time to time as may be needed in the credit evaluation and review process and waives any right or claim they would otherwide have under the Fair Credit Reporting Act in the absence of this continuing consent. A Fax or Photocopy of the Authorization shall be as valid as the Original.