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Business

Legal Business Name *

Time in Business *

Type of Business *

Tax I.D. Number *

Business Address *

City *

State/Region *

Postal / Zip Code *

Main Phone Number *

Cell Phone Number *

Email *

Web Address *

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

Legal First Name

Legal Last Name

Home Address (include Suite or Apt #)

Home Street Address

Home City

Home City/Region

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

Home Postal / Zip Code

Percentage of Ownership

First Name Co-Owner

Last Name Co-Owner

Street Address Co-Owner

City Co-Owner

State/Region Co-Owner

Postal / Zip Code Co-Owner

Percentage of Ownership Co-Owner

Partners Capital Sales Rep

Vendor/Dealer Name

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 *

Finance

Business

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

Home Address (include Suite or Apt #)

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

Terms