United Capital Funding Services

Secure Business Lease Application

Lessee

Tax I.D number

Company*

Address*

City*

State* Zip*

Phone*

Fax

E-Mail*

Nature Of Business*

Type Of Business (Check One)*	Years In Business*	Tax Exempts*
Corporation Partnership Sole Proprietor		Yes No

Principal 1*

Title % Ownership*

Home Address*

City*

State* Zip*

Social Security Number *

Principal 2

Title % Ownership

Home Address

City

State Zip

Social Security Number

Bank Information & Trade References

Name Of Bank*

Contact

Phone*

Checking Account Number*

Trade Reference 1

Contact

Phone

Trade Reference 2

Contact

Phone

Vendor/Supplier of Equipment

Vendor

Contact

Phone

Equipment

Description	Price

Total Build Out Cost*

Is the Equipment*	Estimated Delivery Date (Check One)*
New Used	30 Days 60 Days 90 Days Over 90 Days

Structure Requested

Term (Check One)*	Buy Out (Check One)*
36 Months	$1 Buy Out
48 Months	10% Buy Out
60 Months	True Lease

Information Release

By clicking the submit button, I hereby authorize United Capital Funding Services, its designees or assigns to make
business and or personal credit inquiries as necessary throughout the lease. I understand that this may include a
personal credit bureau which will be used in the credit evaluation process. I also authorize United Capital Funding
Services, its designees or assigns to contact me via any means or media deemed necessary.

* = input is required