Please complete the information in the following application to begin the process. If you wish to retain a hardcopy for your records, you may do so by clicking the print form button prior to submitting this form for approval.
 Lessee (Equipment Buyer) Information (*indicates required information)
*Legal Business Name:
Doing Business As (DBA) Name:
*Your Name:
*Your Title:
*Street Address:
*ZIP Code:
*Business Phone:
Cell Phone:
*Years in Business:
Federal ID: (required for business alone)
Is this equipment for business or personal use?
Business   Personal
Type of business?
Corporation   Proprietorship   Partnership  
Date Company Formed (mm/yyyy):
Billing Address (if different)
Zip Code:
Initial Funding Information
*Equipment Description
Fill in ONE of the following fields
Desired Base Payment: $ For Months(Term)
Or Total Equipment Cost: $
* Guarantor Information (Include all owners to account for 100% of company ownership unless Business Alone)
*Guarantor Name:
*Date Of Birth:
*ZIP Code:
Please Authorize:
*The undersigned applies for the lease indicated in this application. Everything stated in this application is correct. TimePayment Corp. may retain the application whether or not the lease is approved. TimePayment Corp. and its Authorized Affiliates are authorized to check my credit and employment history for the purposes of determining my credit worthiness at the time of my application or thereafter in connection with the same transaction or extension of credit and for the further purpose of reviewing the account, taking collection activity on the account, and skip tracing. TimePayment Corp. and its Authorized Affiliates are authorized to provide history information to others about my credit standing and your credit experience with me, including but not limited to credit bureaus, other companies, outside collection agencies and outside attorneys.
I Agree   I Do Not Agree
*Authorized Signature:
*Print Name:
*Adopt this typed representation of my name and title as my signature.
I Agree   I Do Not Agree