Highline Capital

= Required Fields
CUSTOMER INFORMATION

Legally Registered Name

Trade Name or DBA Name

Physical Address (No P.O. Boxes)

City

State	Zip

Referred By




Primary Contact

Phone	Ext.

E-mail



Type of Business	Proprietorship Partnership LLC/LLP S-Corporation C-Corporation

Nature of Business

Years in Business

State of Organization

Federal Tax ID

DUNS #



Parent Company Name/State of Organization

Address

Will Parent Company Guarantee? Yes No


CUSTOMER BORROWING/BANKING INFORMATION:

Institution Name

Account Number

Phone	Ext

Avg. Daily Balance



Institution Name

Account Number

Phone	Ext

Avg. Daily Balance



PRINCIPAL INFORMATION ( required for Proprietorships, Partnerships and privately held corporations )

Principal First Name

Last Name

Title
	(Address, City, State Zip)
Home Address

Phone

% Ownership

Owner Since

SSN

Yes No	Have you guaranteed or co-signed or co-endorsed any other debt?
Yes No	Are you named as beneficiary of a trust, will or estate?
Yes No	Are any of your assets held under a trust agreement of any type, held in an estate or in any other name or capacity?
Yes No	Are any of your assets on deposit, located, or otherwise held outside of the United States of America?
Yes No	Do any of your assets secure any debts other than the debt requested on this application?
Yes No	Are any of your assets located in the community property states of Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin?
Yes No	Have you ever filed for personal bankruptcy, had property you owned foreclosed, or made a settlement or an assignment for the benefit of creditors?
Yes No	Has any corporation or partnership in which you are (were) a major owner or a general partner ever filed for bankruptcy, had property it owned foreclosed, or made settlement or assignment for the benefit of creditors?
Yes No	Are you, or any corporation or partnerships in which you are a major owner or a general partner, a party to any suit or legal action, or are there any unsatisfied judgments against you?
Yes No	Do you have any unpaid or due federal or state income taxes?


Principal First Name

Last Name

Title
	(Address, City, State Zip)
Home Address

Phone

% Ownership

Owner Since

SSN

Yes No	Have you guaranteed or co-signed or co-endorsed any other debt?
Yes No	Are you named as beneficiary of a trust, will or estate?
Yes No	Are any of your assets held under a trust agreement of any type, held in an estate or in any other name or capacity?
Yes No	Are any of your assets on deposit, located, or otherwise held outside of the United States of America?
Yes No	Do any of your assets secure any debts other than the debt requested on this application?
Yes No	Are any of your assets located in the community property states of Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Texas, Washington, or Wisconsin?
Yes No	Have you ever filed for personal bankruptcy, had property you owned foreclosed, or made a settlement or an assignment for the benefit of creditors?
Yes No	Has any corporation or partnership in which you are (were) a major owner or a general partner ever filed for bankruptcy, had property it owned foreclosed, or made settlement or assignment for the benefit of creditors?
Yes No	Are you, or any corporation or partnerships in which you are a major owner or a general partner, a party to any suit or legal action, or are there any unsatisfied judgments against you?
Yes No	Do you have any unpaid or due federal or state income taxes?

VENDOR INFORMATION:

Vendor Name

Address

Contact/Title

Phone Number

Fax Number

E-mail Address


EQUIPMENT INFORMATION:

Equipment Description

Equipment Location

Equipment Cost

Requested End of Term Option	FMV $1 Buyout 10% purchase option

Request Lease Term (months)	24 36 48 60

Expected Delivery Date

Requested Security Deposit



If you have answered yes to any of the above questions details requested by Highline must be submitted to and approved by Highline prior to the funding of any dollar amount requested in the application. I hereby certify that the information contained in this Lease Application is true and accurate to the best of my knowledge, I understand that Highline is relying on the truth and accuracy of the information when making its decision to approve this Lease Application. I hereby authorize Highline Capital Corp., including any subsidiary or affiliate (collectively, "HCC") to request any banks, trade references, financial institutions, or other person(s) or entity(ies) named herein, and any credit reporting services, having information relating to me regarding accounts, account performance, and/or other information, INCLUDING BOTH PERSONAL AND BUSINESS ACCOUNTS AND RELATED INFORMATION, to release such information to HCC in connection with this Lease Application, and at any other time as HCC may determine if this Lease Application is approved. I understand that Highline is relying on this information and its accuracy when making its decision to approve this application.

By choosing "Agree" in the box below, the undersigned hereby certifies to Highline Capital Corp. and/or Highline Capital Transportation, Inc., including their respective successors and assigns (collectively, Highline), that (s)he is, or is an authorized representative of, the customer identified in this Application (Customer), and has obtained proper written approval from any guarantor(s) of Customerís obligations to Highline, and any other principal(s) of Customer and such guarantor(s), and in such representative capacity and by virtue of such written approvals does hereby authorize Highline, to obtain credit information on Customer and guarantor(s), and all principals of Customer and/or any such guarantor(s), including without limitation personal consumer credit information, from any reporting agency selected by Highline to provide such credit information, and the undersigned and Customer agree to defend, indemnify, and hold Highline harmless from any claim or expense Highline may incur arising out of this certification being false, incorrect, or incomplete in any respect.

	I Agree