1239 East Newport Center Drive, Suite 112
Deerfield Beach, FL 33442 Tel: 877-420-0069   Fax: 954-420-5955

Truck Lease Application

Business Information

Business Name:  
Business Address:  
City:     State:     Zip:   		Contact Name:  
Phone:  
Fax:  

Nature of Business:     Years in Business:  
Form of Organization: Proprietorship Corporation Partnership

Personal Information

Name:  
Date of Birth:     Social Security Number:     Number of Dependants:  

Home Phone:     Cell Phone:  

Current Address:

Street:  
City:     State:     Zip:  

Time at Address:   years   months     Rent Own Parents Other
Landlord/Mortgage Holder:     Monthly Payment:  

Previous Address

Street:  
City:     State:     Zip:  

Time at Address:   years   months

Nearest Relative

Name:  
Street:  
City:     State:     Zip:  

Phone:     Relationship:  

Employment Information

Current Employer

Employer Name:  
Street:  
City:     State:     Zip:  

Business Phone:     Position:     Salary:  
Length of Employment:   years   months

Previous Employer

Employer Name:  
Street:  
City:     State:     Zip:  

Business Phone:     Position:  
Length of Employment:   years   months

Co-Applicant Information

Name:  
Date of Birth:     Social Security Number:  

Home Phone:     Cell Phone:  

Current Address:

Street:  
City:     State:     Zip:  

Time at Address:   years   months     Rent Own Parents Other
Landlord/Mortgage Holder:     Monthly Payment:  

Current Employer

Employer Name:  
Street:  
City:     State:     Zip:  

Business Phone:     Position:     Salary:  
Length of Employment:   years   months

Bank Information

Name of Bank:  
Account Number:  
Phone Number:  

References

Equipment Finance Reference:  
Account Number:     Contact:  
Phone Number:     Amount Financed:  

Trade Reference:     Phone Number:  
Trade Reference:     Phone Number:  
Trade Reference:     Phone Number:  

Financial Information

Assets

Cash in Banks:  
Stocks/Bonds:  
Retirement Accounts:  
Cash Value Life Insurance:  
Real Estate:  
Automobiles:  
Other Itemize (Bus. Equip., etc.):  
Total Assets:   		   Liabilities & Net Worth

First Mortgage:  
Equity/2nd Mortgage:  
Auto Debt:  
Notes Due Banks:  
Credit Card Debt:  
Other Debts Itemize:  
Total Liabilities:  
Net Worth:  


Equipment Vendor:     Phone Number:  
Contact:     Selling Price:  
Equipment Description:  



AUTHORIZATION: I understand that this is an application to lease equipment. I authorize R & K Financial Services, Inc. and/or its assigns to obtain a consumer/business credit and/or investigative report on my business or myself. I understand that such information may be derived in whole or in part from Experian, Equifax, Trans-Union, and/or CIC. This is also authorization for my bank to release any account.

By filling in the information below, you agree to this authorization.

Authorization Date:    Day:    Month:    Year:  

Authorized By:    Name:    E-mail: