LEASING APPLICATION
Vendor Informaiton
Alfa Medical Equipment Specialists, Inc.
59 Madison Ave
Hsmpstead, NY 11550
Full Legal
Name______________________________________________________________________________________
Trade Style
_________________________________________
Phone __________________________________________
Address
____________________________________________________________________________________________
Years in Business _________ Years in Business under Present Control
__________ Number of Operations
__________
Corp £ Prop. £ Prshp £ Non-Profit £ If Corp,
Tax I.D. # _________________________
1. Officer’s Name
____________________________________________
Title ___________________________________
Address ________________________________________ Phone____________________ Social Security _____________
2. Officer’s Name
____________________________________________
Title ___________________________________
Address ________________________________________ Phone____________________ Social Security _____________
IF AT ADDRESS LESS
Description
________________________________________________________________________________________
Location of where the equipment will be installed (if different from above) _________________________________________
Total price without Tax ____________________________________ Lease Term (Months)
_________________________
Monthly Payment _______________________________ No. Advance Rental ________________________________
1. Bank Name ___________________________________ Checking £ Savings £ Loan £ Date Open
__________
Authorized Contact ______________________________
Phone ______________________ Acct# ___________________
2. Bank Name ___________________________________ Checking £ Savings £ Loan £ Date Open
__________
Authorized Contact ______________________________
Phone ______________________ Acct# ___________________
Previous Bank
Reference
______________________________________________________________________________
Bank accounts should be open at least for two years. If less, please supply previous bank refences.
1. Name ______________________________ Contact/Acct#
________________________ Phone
____________________
2. Name ______________________________ Contact/Acct#
________________________ Phone
____________________
3. Name ______________________________ Contact/Acct#
________________________ Phone
____________________
after you done entering all the information, kindly print the page and fax to 516-489-9364