Leasing Application

Evans National Leasing Co.
One Grimsby Drive
Hamburg, NY 14075

1-800-416-9080 (Nationwide Toll Free), (716) 873-6800 (Western New York) and (716)873-1002 Fax

To submit an application on the web go to http://www.evansnationalleasing.com

Company Name _______________________________________________
Address ______________________________________________________
City ______________________ State ____ Zip _________ Country ______
Telephone _________________ Fax __________________

Business Information
____ Corporation ____ Partnership ____ Proprietorship
Nature of Business _____________________________________________
Date Started __________________________________________________

Owner Information
Principal (Name/Title)___________________________________________
Social Security________________________________________________
Home Address ________________________________________________
Telephone ____________________________________________________

Bank and Trade References
Bank Reference _______________________________________________
Account # ____________________________________________________
Telephone ____________________________________________________
Contact ______________________________________________________

Trade Reference #1 _____________________________________________
Account # ____________________________________________________
Telephone ____________________________________________________
Contact ______________________________________________________

Trade Reference #2 _____________________________________________
Account # ____________________________________________________
Telephone ____________________________________________________
Contact ______________________________________________________

Trade Reference #3 _____________________________________________
Account # ____________________________________________________
Telephone ____________________________________________________
Contact ______________________________________________________

To secure leasing funding, I authorize all requested bank and trade information to be released by telephone or fax to M&C Leasing Company, Inc. The undersigned hereby waives any privacy of credit information rights or regulations.

Date ___________ Principal's Signature ____________________________

Items to Purchase