Page 1 of 3 Application Progress Please complete all required fields! Equipment Cost(*) Equipment Cost is a required numeric field and must contain a valid currency amount. Desired Term Select Term12 Months24 Months36 Months48 Months60 Months Desired Term is a required field. Equipment Description(*) Equipment Description is a required field. Vendor Invalid Input Sales Rep Carly DeGrasseChris PeedDana DraytonJohn WoehrleKelly J O'BrienMike LaDueNate DoneyRob Mehmet Invalid Input Business Name(*) Legal business name is a required field. Primary Contact(*) Primary contact is a required field. Contact Email(*) Must be a valid email address. Contact Cell #(*) Cell number is a required field. Business(*) Legal business name is a required field. DBA Invalid Input Federal Tax ID Federal Tax ID (EIN) or SSN (Sole Prop) required. Phone #(*) Phone # is a required field. Business Address(*) Address is a required field. Invalid Input (*) StateAL AlabamaAK AlaskaAZ Arizona AR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDC District of Columbia DE DelawareFL Florida GA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT Montana NE Nebraska NV Nevada NH New Hampshire NJ New JerseyNM New MexicoNY New York NC North Carolina ND North DakotaOH OhioOK Oklahoma OR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming City is a required field. State is a required field. Zip Code is a required field. Equipment Location Same as Business Invalid Input (*) Equipment address is a required field. Invalid Input (*) StateAL AlabamaAK AlaskaAZ Arizona AR ArkansasCA CaliforniaCO ColoradoCT Connecticut DE DelawareFL Florida GA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT Montana NE Nebraska NV Nevada NH New Hampshire NJ New JerseyNM New MexicoNY New York NC North Carolina ND North DakotaOH OhioOK Oklahoma OR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Equipment city is a required field. Equipment state is a required field. Equipment zip is a required field. Own/Rent OwnRent Invalid Input Landlord Name Invalid Input Landlord Phone Invalid Input Date Company Est. (under current ownership)(*) Month010203040506070809101112 / Year201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900 Company establishment date is a required field. Legal Structure(*) Select a legal structureCorporationLimited Liability CorporationSole ProprietorshipMunicipalNon-ProfitPartnershipPublicly TradedUnknown Legal Structure is a required field. Bank Name Attach reference document Invalid Input Invalid Input Invalid Input +Invalid Input +-Invalid Input -Invalid Input Owner Name(*) First name is a required field. Alphanumeric and less than 20 characters required (*) Last name is a required field. Invalid Input Primary Contact Invalid Input Primary Contact Invalid Input Invalid Input Must be a valid email address. Email Address(*) Email is a required field. Same as Business Invalid Input Phone #(*) Phone # is a required field. Cell # Phone # is a required field. Home Address New AddressSame as BusinessSame as Equipment Invalid Input (*) Address is a required field. Invalid Input (*) StateAL AlabamaAK AlaskaAZ Arizona AR ArkansasCA CaliforniaCO ColoradoCT Connecticut DC District of Columbia DE DelawareFL Florida GA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT Montana NE Nebraska NV Nevada NH New Hampshire NJ New JerseyNM New MexicoNY New York NC North Carolina ND North DakotaOH OhioOK Oklahoma OR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming City is a required field. State is a required field. Zip is a required field. Date of Birth(*) Month010203040506070809101112 / Day01020304050607080910111213141516171819202122232425262728293031 / 19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 Date of Birth is a required field. Social Security Number(*) Social Security Number is a required field. Citizenship Status(*) Select StatusU.S. CitizenPermanent ResidentTemporary Resident|Other Citizen Permanent Resident Temporary Resident Other % of Ownership(*) Ownership % is a required numeric only field. Owner 2 Owner Name(*) Owner Name is a required field. Alphanumeric and less than 20 characters required (*) Last Name is a required field. Invalid Input Email Address(*) Email is a required field. Same as Business Invalid Input Phone #(*) Phone # is a required field. Cell # Phone # is a required field. Home Address New AddressSame as BusinessSame as Equipment Invalid Input (*) Address is a required field. Invalid Input (*) StateAL AlabamaAK AlaskaAZ Arizona AR ArkansasCA CaliforniaCO ColoradoCT Connecticut DC District of Columbia DE DelawareFL Florida GA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT Montana NE Nebraska NV Nevada NH New Hampshire NJ New JerseyNM New MexicoNY New York NC North Carolina ND North DakotaOH OhioOK Oklahoma OR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming City is a required field. State is a required field. Zip is a required field. Date of Birth(*) Month010203040506070809101112 / Day01020304050607080910111213141516171819202122232425262728293031 / 19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 Date of Birth is a required field. Social Security Number(*) Social Security Number is a required field. Citizenship Status(*) Select StatusU.S. CitizenPermanent ResidentTemporary Resident|Other Citizen Permanent Resident Temporary Resident Other % of Ownership(*) Ownership % is a required numeric only field. Owner 3 Owner Name(*) Owner Name is a required field. Alphanumeric and less than 20 characters required (*) Last Name is a required field. Invalid Input Email Address(*) Email is a required field. Same as Business Invalid Input Phone #(*) Phone # is a required field. Cell # Phone # is a required field. Home Address New AddressSame as BusinessSame as Equipment Invalid Input (*) Address is a required field. Invalid Input (*) StateAL AlabamaAK AlaskaAZ Arizona AR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDC District of Columbia DE DelawareFL Florida GA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT Montana NE Nebraska NV Nevada NH New Hampshire NJ New JerseyNM New MexicoNY New York NC North Carolina ND North DakotaOH OhioOK Oklahoma OR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming City is a required field. State is a required field. Zip is a required field. Date of Birth(*) Month010203040506070809101112 / Day01020304050607080910111213141516171819202122232425262728293031 / 19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 Date of Birth is a required field. Social Security Number(*) Social Security Number is a required field. Citizenship Status(*) Select StatusU.S. CitizenPermanent ResidentTemporary Resident|Other Citizen Permanent Resident Temporary Resident Other % of Ownership(*) Ownership % is a required numeric only field. Owner 4 Owner Name(*) Owner Name is a required field. Alphanumeric and less than 20 characters required (*) Last Name is a required field. Invalid Input Email Address(*) Email is a required field. Same as Business Invalid Input Phone #(*) Phone # is a required field. Cell # Phone # is a required field. Home Address New AddressSame as BusinessSame as Equipment Invalid Input (*) Address is a required field. Invalid Input (*) StateAL AlabamaAK AlaskaAZ Arizona AR ArkansasCA CaliforniaCO ColoradoCT Connecticut DC District of Columbia DE DelawareFL Florida GA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT Montana NE Nebraska NV Nevada NH New Hampshire NJ New JerseyNM New MexicoNY New York NC North Carolina ND North DakotaOH OhioOK Oklahoma OR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming City is a required field. State is a required field. Zip is a required field. Date of Birth(*) Month010203040506070809101112 / Day01020304050607080910111213141516171819202122232425262728293031 / 19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 Date of Birth is a required field. Social Security Number(*) Social Security Number is a required field. Citizenship Status(*) Select StatusU.S. CitizenPermanent ResidentTemporary Resident|Other Citizen Permanent Resident Temporary Resident Other % of Ownership(*) Ownership % is a required numeric only field. Owner 5 Owner Name(*) Owner Name is a required field. Alphanumeric and less than 20 characters required (*) Last Name is a required field. Invalid Input Email Address(*) Email is a required field. Same as Business Invalid Input Phone #(*) Phone # is a required field. Cell # Phone # is a required field. Home Address New AddressSame as BusinessSame as Equipment Invalid Input (*) Address is a required field. Invalid Input (*) StateAL AlabamaAK AlaskaAZ Arizona AR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDC District of Columbia DE DelawareFL Florida GA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT Montana NE Nebraska NV Nevada NH New Hampshire NJ New JerseyNM New MexicoNY New York NC North Carolina ND North DakotaOH OhioOK Oklahoma OR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming City is a required field. State is a required field. Zip is a required field. Date of Birth(*) Month010203040506070809101112 / Day01020304050607080910111213141516171819202122232425262728293031 / 19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 Date of Birth is a required field. Citizenship Status(*) Select StatusU.S. CitizenPermanent ResidentTemporary Resident|Other Citizen Permanent Resident Temporary Resident Other Social Security Number(*) Social Security Number is a required field. % of Ownership(*) Ownership % is a required numeric only field. Owner 6 Owner Name(*) Owner Name is a required field. Alphanumeric and less than 20 characters required (*) Last Name is a required field. Invalid Input Email Address(*) Email is a required field. Same as Business Invalid Input Phone #(*) Phone # is a required field. Cell # Phone # is a required field. Home Address New AddressSame as BusinessSame as Equipment Invalid Input (*) Address is a required field. Invalid Input (*) StateAL AlabamaAK AlaskaAZ Arizona AR ArkansasCA CaliforniaCO ColoradoCT Connecticut DC District of Columbia DE DelawareFL Florida GA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT Montana NE Nebraska NV Nevada NH New Hampshire NJ New JerseyNM New MexicoNY New York NC North Carolina ND North DakotaOH OhioOK Oklahoma OR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming City is a required field. State is a required field. Zip is a required field. Date of Birth(*) Month010203040506070809101112 / Day01020304050607080910111213141516171819202122232425262728293031 / 19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015 Date of Birth is a required field. Social Security Number(*) Social Security Number is a required field. Citizenship Status(*) Select StatusU.S. CitizenPermanent ResidentTemporary Resident|Other Citizen Permanent Resident Temporary Resident Other % of Ownership(*) Ownership % is a required numeric only field. Total Ownership: 0% + Add Owner Invalid Input + Add Owner- Del Owner Invalid Input + Add Owner- Del Owner Invalid Input + Add Owner- Del Owner Invalid Input + Add Owner- Del Owner Invalid Input - Del Owner Invalid Input Terms and Conditions By checking this box, the applicant(s) certifies that all information contained in this application, and all attachments hereto, are true and accurate to the best of the applicant(s) knowledge and are made for the purpose of obtaining credit for business purposes, and not for personal or family use. The applicant(s) hereby authorize Geneva Capital L.L.C. and its assigns to obtain and use consumer credit reports on the undersigned, now and from time to time, as may be needed in the credit evaluation and review process if credit is extended and waives any right or claim the applicant(s) would otherwise have under the Fair Credit Reporting Act in absence of this continuing consent. The applicant(s) further authorize any government agency, bank or financial institution to release credit information on the applicant(s) accounts to Geneva Capital L.L.C. and its assigns. If credit is extended, Applicant agrees that by selecting the “Submit Application Securely” button this electronically transmitted application shall be deemed to be binding, valid, genuine and authentic as an original-signature document for all purposes. The applicant(s) further authorize Geneva Capital L.L.C. to mail, text, fax or e-mail solicitations of future lease financing services to applicant and or collections of payment. I agree Authorization must be checked. I agree Authorization must be checked. I agree Authorization must be checked. I agree Authorization must be checked. I agree Authorization must be checked. I agree Authorization must be checked.
