LEASING

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LESSEE COMPANY INFORMATION
Company Name
Company Address City State, Zip Fed Tax Id.
Signer
Title Telephone
Type of Business
Non Profit Proprietorship
Partnership Corporation
Time in business under current ownership
PERSONAL INFORMATION ON OFFICERS, PARTNERS OR GUARANTORS
Name

Title

SSN #
% Ownership
Own/Rent
Present Home
Home Address

City

State
Zip
How long?
Home Phone Number
Name

Title

SSN #
% Ownership
Own/Rent
Present Home
Home Address

City

State
Zip
How long?
Home Phone Number
COMPANY BANK REFERENCES -- TWO YEAR HISTORY
Name of Bank / Branch How Long? Chkg Acct. # Telephone Contact Officer
Name of Bank / Branch How Long? Chkg Acct. # Telephone Contact Officer
TRADE REFERENCES -- TWO YEAR HISTORY
Name of Supplier City / State Telephone Contact Person
Name of Supplier City / State Telephone Contact Person
LEASE / LOAN REFERENCES -- SIX MONTH PAY HISTORY
Name
Amount $
Loan Acct. #
Contact Person
EQUIPMENT DESCRIPTION
DECLARATION

The above information, together with any accompanying financial statements, schedules, or other materials, is submitted for the purpose of obtaining credit and is warranted to be true, correct and complete. The undersigned hereby warrants that any individual identified above who is either a principal, a personal guarantor or a sole proprietor of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, has provided his/her written authorization for inquiry into their credit worthiness, including but not limited to obtaining a consumer credit report, and shall hold Balboa Capital and its assignees, agents or nominees harmless from same. You understand that such investigation may include seeking information as to the background, credit and financial responsibility of your officers and principals (or any of them). The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status or age (provided the applicant has the capacity to enter into the binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. If for any reason your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please write to Balboa Capital Corp., 2010 Main Street, 11th Floor, Irvine, CA 92614 within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial of credit within 30 days of receiving your request for the statement.

Applicant Signature Title Date