Equipment Leasing Application | VIP Payment Solutions
Personal Information
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    ** Please fill out all "Required" fields **    
First Name:
Last Name:
Home Address:
City:
State:
Zip/Postal code:
Phone(Mobile): ex: 310-987-1234
Fax: ex: 310-987-1234
Date of Birth: ex: (01/28/1975)
Email:
Business Information
   Sole Proprietor    Corporation    LLC    Partnership    Other   
  ex: 12-3456789
Doing Business As (DBA):
Business Legal Name:
Business Address:
City:
State:
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.)
Comments:
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