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Company Name:
DBA (if different):
Address:
City:
State:
Zip:
Phone:
Fax:
Mobile:
E-mail:
Federal Tax ID or Social:
Type of Business:
No. of Employees:
Contact Name:
Title:
Time in Business:
Business Structure
Are You A:
Duns #:
(Dunn & Bradstreet Number)
State of Incorporation:
Personal Information:
* Required on all companies under 3-years in business and all proprietorships, partnerships and LLC's
Principle/Officer #1:
Title:
SSN:
Home Address:
City:
State:
Zip:
Principle/Officer #2:
Title:
SSN:
Home Address:
City:
State:
Zip:
Trade References:
Name (Reference #1):
Phone (Reference #1):
Name (Reference #2):
Phone (Reference #2):
Bank References:
Name of Bank (1):
Phone:
Contact Person:
Account #
Date Opened:
Name of Bank (2):
Phone:
Contact Person:
Account #
Date Opened:
Purchase Details:
Amount Requested:
$
Terms Requested:
End of Lease Options:

This document should serve as notice to you that I/we are considering an equipment acquisition. This document will serve as your authorization to release any or all credit information regarding my/our account(s) and any or all corporate financial statements on file to any leasing company, bank or financial institution that may be involved in providing credit accommodations for the acquisition of this equipment.

I agree the information provided here is accurate and I am allowing access to my financial statemments to Ritalia Funding for the purpose of financing.

Submitted by:
Title:




Ritalia Funding
1-800-249-9189

10532 Topeka Drive
Northridge, CA 91326
Ritalia Funding
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