Equipment Leasing Application | VIP Payment Solutions
Personal Information
= Required fields / Digital Encryption Enabled for
= Vietnamese translation / For security reasons, language switching is disabled
    ** Please fill out all "Required" fields **    
First Name:
Last Name:
Home Address:
Zip/Postal code:
Phone(Mobile): ex: 310-987-1234
Fax: ex: 310-987-1234
Date of Birth: ex: (01/28/1975)
Business Information
   Sole Proprietor    Corporation    LLC    Partnership    Other   
  ex: 12-3456789
Doing Business As (DBA):
Business Legal Name:
Business Address:
Zip/Postal code:
Business Phone: ex: 310-987-1234
Business original start date: ex: 01/01/2009 (by original owner)
Length of time you owned the business:  Years 
Type of Industry:  
Length of time you owned the business:  Years 
Amount of finance needed: $ (Equipment cost, excluding sales tax)
Equiment Description: (X-ray, refrigerator, Spa Chair, etc.)
Business bank account with: (Chase, Wells Fargo, Bank of America, etc.)
Privacy & Security Policy
We use the latest encryption technologies to protect sensitive information transmitted online. We are the sole owners of the information collected on this site and only have access to/collect information that you voluntarily give us via email or other direct contact (i.e. phone or fax). We will never sell or rent this information to anyone.    Read More >>