By submitting this form, you authorize AMTEC or any credit bureau or other investigative agency employed by AMTEC to investigate the references herein listed or statements or other data obtained from you or from any other person pertaining to your credit and financial responsibility.

If you'd rather, you may print and fax this form to 210-349-8465.

Legal Company Name		Vendor Name
Address		Address
Phone		Phone
How long has company been in business?		Type of Business
Company is a: Corporation Partnership Proprietorship

OWNERS/OFFICERS
Full Name	Address	Social Security No.

Full Name	Address	Social Security No.

BANK REFERENCES
BANK	OFFICER	ACCOUNT NO.	PHONE

TRADE REFERENCES
FIRM NAME	CONTACT	CITY	PHONE

EQUIPMENT TO BE LEASED
QUANTITY	DESCRIPTION	MODEL	PRICE
		TERMS	12 mo 24 mo 36 mo 48 mo 60 mo