Please PRINT, COMPLETE & FAX this application to (800) 535-8576 
For Questions call: Shawn Kook or Gail Little at 1-800-426-3194		 DATE: ___________________________________
      

BUSINESS/PROPOSAL INFORMATION
Business Name How Long Established Under current Ownership?
Business Address How long at this Address?
Line Of Business Phone:                                                    FAX:
Previous Employment               Company Name                   Position           How Long?            Phone #
(If in Business less than 2 years)                                                                                                                                       
 OWNERSHIP:  Proprietorship :___   Partnership:___  Corporation:___   Non-Profit:___  FEDERAL TAX ID # :__________________
Name of Principals/Title Soc. Sec. Number   % Owned  Phone Number
       
RENT: ___ OWN: ___ ADDRESS:                                                                      City:                                          State:           Zip:
       
RENT: ___ OWN: ___ ADDRESS:                                                                      City:                                          State:           Zip:
TRADE/INSTALLMENT LOAN AND LEASE REFERENCES
COMPANY NAME CONTACT PHONE NUMBER ADDRESS
       
       
       
       
       
BANK ACCOUNT AND LOAN REFERENCES
BANK NAME BRANCH PHONE NUMBER BANK OFFICER ACCOUNT # ACCT. TYPE
          Business: ___
Personal: ___
          Business: ___
Personal: ___
EQUIPMENT NEW USED QUANTITY MODEL SERIAL #
           
           

TO BE FILED OUT BY LEASING COMPANY: PLAN:                                   AMOUNT $                                FACTOR /RATE:  

No. of MONTHS   TAX$                  MONTHLY PAYMENT$                       TOTAL$                         ADVANCE PAYMENT$
VENDOR:     ICM of Birmingham        PHONE:  205-410-8875   FAX: 205-744-3711
Your cooperation in fully completing this application will expedite approval of your lease.      THANKS FOR YOUR HELP
         I authorize you to obtain such information as you may require concerning the statement contained in this application, including TRW/Credit reports on individuals listed above, and agree that the application shall remain your property, whether or not the lease is granted. I hereby verify all statements contained in this application are true and complete, and are made for the purpose of obtaining credit. DATE:__________ SIGNATURE:____________________________________________________