Business Address

Postal / Zip Code

Email Address

Web Address

Legal Name of Owner (as it appears on driver's license)

Home Address (include Suite or Apt #)

Postal / Zip Code

Legal Name of Co-Owner (as it appears on driver's license)

Home Address (include Suite or Apt #)

Postal / Zip Code

Equipment Description & Cost

Term(s) Requested (months)

Terms

The preceding information is for the purpose of obtaining credit and is warranted to be true. I/We hereby authorize.

International Diagnostic Equipment, LLC to investigate all references and customary credit information sources including consumer credit reporting repositories (see Consent to Obtain Consumer Credit Report below) regarding my/our credit and financial responsibility for the purpose of obtaining credit and for periodic review for the purpose of maintaining the credit relationship.

I agree to the terms and conditions specified above

By signing below, you understand that you are providing 'written instructions' under the Fair Credit Reporting Act authorizing the credit grantor to obtain information from your personal credit profile or other information from a consumer reporting agency. You authorize this credit guarantor to obtain such information solely to apply for credit.

Signature of Applicant

Date