Applicant Information:

Legal Company Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Web Address:

Entity Type: (check one)

Federal Tax ID:

Tax Exempt? (check one)

Yes No

Year Established

(1) Principal Owner

Title

Social Sec. Number

Date of Birth

Address

City

State

Zip Code

(2) Principal Owner

Title

Social Sec. Number

Date of Birth

Address

City

State

Zip Code

Affiliated Companies or Subsidiaries:

Credit References:

Bank Name:

Account Number(s):

Contact:

Phone:

(1) Finance Company

Account Number(s)

Contact:

Phone:

(2) Finance Company

Account Number(s)

Contact:

Phone:

Trade References:

(1) Company Name

Product/Supplies

Contact:

Phone:

(2) Company Name

Product/Supplies

Contact:

Phone:

Year/Make/Model

Specifications

Delivery Date

Cost

Equipment is Addition

Equipment is Replacement - payment:

Salesperson's Name:

The information given above is true and complete. Lynch Chicago, Inc. and its Assignees may receive from and disclose to other persons, including credit reporting agencies, information about Applicant accounts and credit experiences and Applicant authorizes any person to release to Lynch Chicago, Inc. and its Assignees credit experience and account information on Applicant(s). This shall be a continuing authorization for all present and future disclosures of account information and credit experience on Applicant(s) made by Lynch Chicago, Inc. and its Assignees, or any person requested to release such information to Lynch Chicago, Inc. and its Assignees.