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Equipment Finance Application
Financing Types
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Lease
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Company Information
Company Name
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Dealership Name
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Account Number
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Primary Contact
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Dealer Contact
*
*
Dealer Phone
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Dealer Email
*
*
DBA
*
Fed Tax ID
*
Business Phone
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*
Entity Type
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Corporation
LLC
LLP
Municipality
Nonprofit 501(c)(3)
Partnership
S Corp
Sole Proprietorship
Trust
Industry
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Agriculture
Construction
Demolition
Electrical Work
Forestry
Landscape
Material Handling and Warehousing
Mining
Plumbing ,Heating and Air-Conditioning
Rental
Snow & Ice
Waste Management and Recycling
Others - List
Others Industries
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Physical Address
*
*
Physical City
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*
Physical State
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AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Physical Zip/Postal Code
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*
Mailing address
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Mailing address
No
Mailing address
Yes
State of Inc
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AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Business Start Date
*
*
Estimated Annual Revenue
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$0 - $100,000
$100,001 - $200,000
$200,001 - $300,000
$300,001 - $400,000
$400,001 - $500,000
$500,001 - $750,000
$7500,001 - $1,000,000
$1,000,001 - $3,000,000
$3,000,001 - $5,000,000
$5,000,001 - $10,000,000
$10,000,001+
Dates
Credit Decision Timestamp
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Minutes To Credit Decision
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Equipment To Be Purchased
Equipment Description
*
*
Equipment Condition
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New
Used
Equipment Price
*
*
Equipment Chassis #
*
Notes
*
*
By submitting this form, the individual(s) who is either a principal of the credit applicant listed above and/or a guarantor of its obligations, provides authorization to ZAXIS Finance its affiliates and its designees (and any nominee, assignee or potential assignee thereof) to obtain and review his/her personal consumer credit report from a consumer credit reporting agency. This authorization shall extend to obtaining a consumer credit report, and additional consumer credit reports, now and again in the future for the purpose of (i) credit evaluation, assessing financial condition and review, including updating, renewing and/or the extending of such credit and/or (ii) reviewing and/or collecting the resulting account, now and from time to time. This authorization applies to this application, any future applications, any requests by you and/or applicant for credit and any solicitations by us to offer you and/or applicant credit. I/we waive any right or claim they would otherwise have under the Fair Credit Reporting Act in the absence of this continuing consent. In addition to authorizing the review of my / our consumer credit report from any consumer credit reporting agency, the undersigned also authorizes my/our financial institutions and creditors to release credit information required by ZAXIS Finance and its designees (and any assignee or potential assignee thereof). By typing your name in the box below, I/we affirm our identity as the respective individuals identified in the related application. The undersigned states that all of the statements and information in the application are true & complete
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Guarantor or Primary Contact Information
First Name
*
*
Last Name
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*
Email address
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*
Mobile Phone
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*
Title
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*
Ownership %
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*
*
Home Address
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*
Home City
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*
Home State
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AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Home Zip Code
*
*
Social Security Number
*
*
Date of Birth
*
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