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1. Company Information

Legal Name of Business*

Doing Business AS (DBA)

Business Address*

Type of Business*
—Please choose an option—C CorpS CorpLLCPartnershipSole Prop

Tax ID Number

D&B Number

Contact Name & Title*

Contact Email Address*

2. Ownership Information

Principal/Owner

Percentage of Ownership

Date of Birth (DOB)

Home Address

Cell Phone Number

Email Address

3. Equipment Information

Vendor Name

Equipment Model/Description

Amount Requested*

Requested Terms*
—Please choose an option—12 months24 months36 months48 months60 months72 months

End of Lease Buyout*
—Please choose an option—One Dollar BuyoutFair Market ValueLoan/Finance Agreement

4. Release Statement

I authorize our bank(s), trade references, and financial institutions to release information by fax or email to First Option Capital and/or its assigns. Further, I authorize First Option Capital or its assigns to obtain other credit information including but not limited to D&B and Credit Bureau Reports, etc.

Applicant Full Name*

Signature (Enter Initials as Digital Signature)*

Title*

Date (MM/DD/YYYY)*