Equipment Financing Application

Company Information
Company Type:
Company Legal Name*:
Date Established Under Current Ownership:
Company Address*:
City, State, Zip*:
Phone*:
Fax:
Federal Tax ID Number:
County*:
Lessee Contact:
Email Address:
Equipment Location:
County:
Annual Practice Gross Revenue*:
   
Bank Reference
Bank 1  
Bank Name:
City, State:
Phone:
Contact:
Account Number:
   
Bank 2  
Bank Name:
City, State:
Phone:
Contact:
Account Number:
   
Personal Information
Principal 1  
Principal Name*:
Street Address*:
City, State, Zip*:
Phone*:
Social Security Number*:
Professional License Number*:
Date of Birth*:
   
Principal 2  
Principal Name:
Street Address:
City, State, Zip:
Phone:
Social Security Number:
Professional License Number:
Date of Birth:
   
Equipment Information
Type:
Equipment Supplier*:
Contact:
Phone:
Equipment Cost*:
Request Term:
   
* Indicates a required field
 
Signatures
We intend to apply for joint credit     (initials)
Digital Signature*: (Full Name)    |    Date:
Digital Signature: (Full Name)    |    Date:
 

Applicant hereby authorizes the release of business and/or personal credit information to One Place Capital - Bank Midwest, its affiliates and partners, (1) from any source including credit bureau reporting agencies and applicant's bank for the purpose of extending credit, (2) to any credit reporting agency. I hereby represent all information is true, correct and complete. A photo static and/or facsimile copy of this authorization shall be valid as the original. If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact: Credit Operations, One Place Capital, 5625 Mills Civic Parkway, Suite 101, West Des Moines, IA 50266, or call 888.394.0186 within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement.

NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (providing the applicant has the capacity to enter into a binding contract), because all of or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The Federal Agency that administers compliance with this law concerning this creditor is: Federal Reserve Consumer Help Center, PO Box 1200, Minneapolis, MN 55480