Lease Application A Program Administered by Provident Capital Group, Inc.
Legal Company Name:				Contact:
Billing Address:				Phone:
City:	County:	State:	Zip:	Fax:
Equipment Location:				Phone:
City:	County:	State:	Zip:	Fax:
Type of Business:		Fed Tax #:		Yrs Bus:
Insurance Company:			Phone:	Fax:
Landlord or Mortgage Holder:				Phone:
Ownership: Sole Owner Partnership Corporation Other

Principal or Officer & Title	% Owned	Home Address, Street, City, State, Zip	Phone	Social Security #

Bank Branch	Branch Officer	Phone	Account Number

Trades	Account #	Contact	Phone	Fax
Comparable Credit (lease/loan)	Account #	Contact	Phone	Fax
I, the undersigned, hereby authorize the release of credit information, and request that all loan, credit, bank, trade or other history be given as needed to Provident Capital Group, Inc. Or its assigns. I also understand that the use of a photocopy of this release may be necessary to verify my history. I authorize the use of such a copy and request that it be honored fully, as if we original

BY:

TITLE:

DATE:

EQUIPMENT TO BE LEASED
Dealer Name: Agency Telephone			Contact: Ned Burns	Phone: (609) 933-0393
Address: 900 Creek Road, Bellmawr, NJ 08031				Fax: (609) 933-2042
Equipment Description			Cost:	New Old
Lease Term: 24 MO 36 MO 48 MO 60 MO			Residual: $1 10% FMV
If your application for business credit is denied, you have the right under the Federal Equal Credit Opportunity Act (Regulation B) to request a written statement of the reasons(s) for your denial. To obtain such a statement, please submit your written request to Provident Capital Group, Inc. within 60 days from the date you were notified of our decision.

Agency Telecommunications
900 Creek Road
Bellmawr, NJ 08031
(609) 933-0393
Fax: (609) 933-2042
(800) 525-0966