TELL US ABOUT YOU

Please Select One Are You A Principal/Borrower Attorney Bank CPA Financial Institution Other	Brokers Please Click Here
Your Name
Company Name
Your Position/Title With Company
City & State
Website Address (if Any)
E-Mail Address
Telephone
Facsimile

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TELL US ABOUT BORROWER

Company Name
City & State
Owner's Name
Type of Ownership	Corporation S Corporation Sole Proprietorship Partnership Limited Liability Company
How Long In Business?
Is Your Company Public or Private?

If Public, Please Enter Symbol
Type of Business

Owner's E-Mail Address
Owner's Telephone
Owner's Facsimile
Company Website Address (If Any)
Do You Personally or Your Business Have Any Credit Problems? NoYes	If Yes, Please Explain
Has Your Company Been Profitable For The Last 3 Years? Yes No	If No, Please Explain
Any Lawsuits or Litigation Pending Against Borrower or Property?	No Yes If Yes, Please Explain

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ABOUT YOUR REQUEST

APPLYING FOR: Equipment Loan Equipment Lease Sale-Leaseback Other Acquisition Consulting Debt Restructuring Expansion Refinance Other

Amount Requested
Use of Funds
Desired Terms

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ABOUT THE EQUIPMENT

Type of Equipment New Used Rebuilt Reconditioned

Value Of Equipment

If Equipment Purchase - Please Provide:

Vendor Name		Equipment Description NewUsed
Telephone		Equipment Location
Facsimile		Total Sales Price
Address		Down Payment
Salesperson		Purchase Option (if applicable)
Price Per Unit		Number of Units (Quantity)

If Refinancing Equipment Or Sale-Leaseback - Please Provide:

Description of Equipment and Number of Items
General Condition of Equipment
Total Estimated Value
Average Value Per Unit
Date(s) of Purchase
Original Purchased Price
Original Down Payment

Describe Other or Additional Collateral Here 

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COMPANY REVENUES

Last Year's Sales	Sales YTD

MOST RECENT BALANCE SHEET

Total Assets
Total Liabilities
Net Worth

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HOW MANY OTHER LENDERS HAVE SEEN THIS DEAL?
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