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ETA Member

Leasing Application

This form will submit directly to Adia Capital, LLC. If you are unable to provide some of the required information, please enter an explanation, or type NA. If you have any questions, please contact Adia Capital directly at 866-757-0244 (toll free).

Please complete all required (*) information to submit the leasing application.

Vendor Information

Sales Representative:
*
Equipment Description:
*
Equipment Cost:
Condition:
New Used
Lease Term:
Monthly Payment:
$
Purchase Option:
FMV 1.00 10% Other

Business Information

DBA (if any):
*
Company Name:
*
Business Address:
*
City:
*
State:
*
Zip:
*
Phone:
Fax:
*
Email:

Must be a vaild email address
*
Business Established:
*
Type of Business:
Non-Profit
C Corp
Proprietorship
Partnership
SUB "S" CORP
L.L.C.
*
Tax ID:
#
*
Nature of Business:
*
Equipment Location:
*
Has the applicant or any guarantor ever had:
Repossession
Bankruptcy
Judgment
None

Information on Principals

Principal 1

*
Your Name:
Title:
*
Social Security Number:
#
*
Address:
*
City:
*
State:
*
Zip:
*
Do you:
Rent
Own
*
Percentage of Ownership:
*
Place of Employment:
*
Home Phone:
*
Cell Phone:
*
Work Phone:
*
Email:

Principal 2

Your Name:
Title:
Social Security Number:
#
Address:
City:
State:
Zip:
Do you:
Rent
Own
Percentage of Ownership:
Place of Employment:
Home Phone:
Cell Phone:
Work Phone:
Email:

Principal 3

Your Name:
Title:
Social Security Number:
#
Address:
City:
State:
Zip:
Do you:
Rent
Own
Percentage of Ownership:
Place of Employment:
Home Phone:
Cell Phone:
Work Phone:
Email:

Bank References

Reference 1

Name:
Phone Number:
Account Number:
#
Contact:

Reference 2

Name:
Phone Number:
Account Number:
#
Contact:

References

Closest relative not living with you

*
Name:
*
Phone Number:
*
Address:

Personal Reference

*
Name:
*
Phone Number:
*
Address:
I / We hereby authorize the release of any and all credit information to Adia Capital, LCC from the above listed references, and certify that all is true and correct to the best of my knowledge. The undersigned individual(s), recognizing that his/her/their individual credit histories may be a factor in the evaluation of undersigned, now and from time to time, as may be needed in the credit evaluation and review process and waives any right or claim they would otherwise have under the Fair Credit Reporting Act in the absence of this continuing consent.

Please type I AGREE or I DISAGREE in the following box to acknowledge your authorization.
*