Welcome to Premium Finance Solutions

www.premiumfinancesolutions.com

Application for Equipment Leasing Form

Business Name:

How long established?

years

Business Address:

How long at this address?

years

Type of Business:

Phone #:

Location of Equipment if other than business address:

Fax #:

Ownership:

Federal Tax #:

Name of Principals/Title:

Home Address:

Social Security #:

Trade References:

Phone #:

Address:

Bank References:

Phone #:

Bank Office:

Account # (last 9 digits):

Bus/Per:

Insurance Agent or Broker:

Address:

Phone #:

Supplier of Equipment:

Address:

Phone #:

Description of Equipment (Manufacturers, Model #, Serial #):

List Price $:		Advance Payment:
Sales Tax $:		Total $:
Delivery:		Term of Lease:

I certify that all statements are true to the best of my knowledge, and I hereby authorize Premium Finance Solutions, Inc. and their assignees to obtain any information required concerning the statements in this application to include all bank references.


Authorized Signature*	Title

*Entering your complete name will represent your signature as an applicant.

Premium Finance Solutions, Inc.
1911 Foothill Blvd., #149
La Verne, CA 91750-3511
909-964-1701 Fax: 413-751-9884
E-mail: pfsolutions@adelphia.net
"Insurance Premium Finance & Commercial Lending Solutions"
We are proud to be a member of the American Cash Flow Association.

QUICK LINKS:

• Mission Statement
• Insurance Premium Financing
• Reasons to Sell Cash Flows
• Asset Protection
• Selling Private Mortgage Notes
• Receivable Funding/Factoring
• Structured Settlements
• Leasing
• Apply Online