Medical Equipment Financing with form

The undersigned principal(s) certify that he/she has full authority to act on behalf of the applicant. The applicant (if a sole proprietor), principals, and guarantors each certifythat all of the information contained in this application and on each document required to be submitted in connection herewith are true and complete. The applicant (if a sole proprietor) and each guarantor hereby authorize Leasecap and its Assigns to obtain his/her credit profile from the national credit bureau(s) for the purpose of considering this credit application and any subsequent update, renewal, collection or additional credit. A photocopy or facsimile of this authorization shall be as valid as the original. Further, the applicant and guarantors hereby authorize each bank and finance reference listed in this credit application to release information about the applicants and guarantors to Leasecap and its Assigns, as requested by Leasecap. If your application for business credit is denied you have the right to a written statement of the specific reasons for the denial by writing to Leasecap, within sixty (60) days from the date you are notified of our decision. Leasecap will send you a written statement of the reasons for the denial within thirty (30) days of receiving your request for the statement.

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, or age (provided the applicant has the capacity to enter into a binding contract); or because all 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. By signing below, I also wish to continue to receive updates from Leasecap regarding our account. Information should be sent to the fax and/or e-mail address provided for this account.