Vending Equipment Sales & Service

Vendor Information

Vendor Name

Phone Number

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Contact Name

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� Type of Lease

Number of Months (Select one)���������� Type of Lease (Select one)��������������������� Equipment Cost (without tax)

 

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Equipment to be leased - ( include make, model & serial #�s and any attachments

Customer Information

Company Name

Address

City

State

Zip

Phone Number

Cell Phone

Fax Number

E-Mail Address

Corporation

�Check One

Partnership

Propiertorship

Number of years

Principal/Partner/Officer

% Owned

Lessee Contact

Principal/Partner/Officer

% Owned

Home Address

Home Address

City, State, Zip

City, State, Zip

Home Phone

Social Security Number

Home Phone

Social Security Number

Trade Reference

Supplier

Supplier

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Phone Number

Contact������

Phone Number

Bank Reference

Bank Name

Checking Account #

Phone Number

Contact Name

*To help expedite the approval process 2-3 months of bank statements may be requested.

By providing the above information, the applicant(s) authorize you to who this application is made or your agents to���� investigate financial responsibility and credit worthiness and will provide financial statements, tax returns, etc. as deemed necessary.� I/we authorize you to update my/our credit profile from time to time in the future as you deem appropriate.�

When form is complete, click on the SUBMIT button  

Form may be printed out and mailed to The Hanna Group as an alternative to submitting through the website.