Performance Capital Corp.
Tele: (954) 523-0733
Fax: (954) 523-0766

CREDIT APPLICATION

COMPANY INFORMATION

Company's Exact Registered Name Including any DBA
Street Address
City
County
State
ZIP
Date of Incorporation/Years Under Present Ownership
Contact Person
Telephone #
Fax #
Nature of Operations
SIC Code
Business Type Corporation Proprietor Partnership Non-Profit


INFORMATION ON ALL OFFICERS OR PARTNERS OF THE BUSINESS

Officer's Name 1
S.S.#
Title
Ownership %
Home Phone #

Address

 

Officer's Name 2
S.S.#
Title
Ownership %
Home Phone #

Address

 



EQUIPMENT INFORMATION

Total Price without tax
Requested lease terms (months)
Description
Vendor Name & Telephone


BANK INFORMATION

Bank Name
Authorized Contact
Phone #
Account Type Checking Savings Loan
Date Open
Account #

Bank Name
Authorized Contact
Phone #
Account Type Checking Savings Loan
Date Open
Account #


LEASE / TRADE REFERENCES

Name
Contact / Account #
Phone #

Name
Contact / Account #
Phone #

Name
Contact / Account #
Phone #



EQUAL CREDIT OPPORTUNITY ACT NOTICE: If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial, to obtain this statement, please contact our chief credit officer, 600 South Andrews Avenue, Fort Lauderdale, FL 33301 within 60 days from the date you are notified of our decision. We will send a written statement of the reasons for denial within 30 days of receiving your request for the statement. The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the consumer credit protection act. The federal agency that administers compliance with this law concerning this creditor is the federal trade commission, equal credit opportunity, Washington, DC 20580.

The undersigned certifies that the information requested above is accurate. The lessee named above, its owners and principals, and all individuals whose names appear on the application expressly authorize consumer reporting agencies and other persons to furnish credit information to Performance Capital Corporation, separately or jointly with other creditors or lessors, for use in connection with this Agreement, Lessors and joint users of such information are authorized to receive and exchange credit information and to update such information as appropriate during the term of this Agreement. Information about you may be used for marketing and administrative purposes and shared with our affiliates. However, you may direct us not to share with our affiliates certain information (other than transaction or experience information) about you by writing to us at Performance Capital Corporation, Attn: Vice President , Operations, 600 South Andrews Avenue, Fort Lauderdale, FL 33301. (Please include your social security number).

All lease applications and agreements are subject to approval by Performance Capital Corporation. I/We hereby authorize Performance Capital Corporation to investigate my/our past and present business relationships, banking relationships (personal and business) and creditworthiness and, should I be asked, I will provide financial statements, tax returns or other information necessary to approve this application. I warrant and agree that in the above information, after due independent inquiry, is complete and accurate.

Signature : ___________________________________ Title: _____________ Date: _______________