Customer Application Form Page 3
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CUSTOMER APPLICATION FORM (CONT.)
Trade Reference Name: _____________________________________________
Street Address: ____________________________________________________
City, State and Zip Code: ____________________________________________
Account #: ________________________________________________________
Contact: __________________________________________________________
Phone (Include Area Code): ___________________________________________
Brief Description of Reference:________________________________________________________________
_________________________________________________________________________________________
Trade Reference Name: _____________________________________________
Street Address: ____________________________________________________
City, State and Zip Code: ____________________________________________
Account #: ________________________________________________________
Contact: __________________________________________________________
Phone (Include Area Code): ___________________________________________
Brief Description of Reference:________________________________________________________________
_________________________________________________________________________________________
A copy of your most recent year-end financial statement is appreciated. Financial statements are required for all lease agreements of 12 months or longer and
for self-insurance requests.
Please check your information to make sure it is correct before you submit. Thank you.
By signing below, (1) I represent and warrant that I am authorized to agree to the Standard Terms and Conditions on behalf of the applicant, (2) I am the
individual identified above, (3) I understand that I am personally guaranteeing payment of all lease agreements entered into by and on behalf of the company
for which this application is submitted, and (4) I understand that I am agreeing to the Standard Terms and Conditions on behalf of the applicant. A copy of the
Standard Terms and Conditions may be found on our company web site at
Date: _________________________
By: ____________________________________________
Print: ___________________________________________
Title:___________________________________________
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