Lessee Appliction for Creditl

Please complete the form below and click "Submit" to apply for credit through OmniFunding.

For your convenience, we also offer a downloadable version that you may fax back to us. This version requires that you have the Adobe Acrobat Reader application installed on you computer.

LESSEE APPLICATION FOR CREDIT
Items marked with an asterisk (*) are required.
*Business Name Filed With State:
*Business Address: Street:
*City:		*State:
*Zip:
*Phone:		Fax:
*Email:
*Equip. Location Address: Street:
*City:		*State:
*Zip:
Web Address:
*Company Contact: First:		Initial:		*Last:
*Practice License #:
*Principal Name: First:		Initial:		*Last:
*Home Address: Street:
*City:		*State:
*Zip:
*Social Security #:
*Business Banking Institution:
*Bus. Acct. #:		*Phone:
*Bus. Landlord:		*Phone:
*Trade Acct. #1 Name:		*Acct #
*Trade Acct. #1 Phone:
Trade Acct. #2 Name:		Acct #
Trade Acct. #2 Phone:
Trade Acct. #3 Name:		Acct #
Trade Acct. #3 Phone:
*Vendor / Manufacturer Name:
*Vendor / Manufacturer Contact:		*Phone:
*What is the legal entity?	Choose... Corporation Partnership Sole Proprietor LLC / LP / LC
*Nature of business?
*Date business established?		*Term:	Choose... 24 36 48 60
YES, I authorize Omni Funding or assigns to contact you for verbal ratings on my bank accounts or trade references. If policy is no verbal ratings, Omni funding will fax an information release to complete and fax back. By signing above, the individual as principle of and/or, guarantor for the credit applicant authorizes Omni Funding, its designee, assigns or potential assigns, the use of consumer credit reports in considering this application, and from time to time as may be needed to: update, renewal, or extension of applicant credit, and for the collection of any resultant accounts. A fax or photocopy of this authorization shall be valid as the original. Please fax to: (801) 566-7458.