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Applicant Information

First Name*

Last Name*

Title*

Email*

Phone*

Fax

Business Information

Legal Business Name*

Doing Business As (If Applicable)

Street Address (One)*

Address (Two) (Suite or Unit)

City*

State*

Zip Code*

Nature of Business*

Structure of Business* Select...CorporationPartnershipNon-profitLLCSole Proprietorship

Age of Business (Years)*

Vendor Information

Vendor Contact* Select contact...GavenRonJasonJoelOther (specify in comments)

Vendor Name

Vendor Phone

Vendor Fax

Equipment & Lease Details

Equipment to be Leased

Intermountain Sales Quote Number (IMSQ)

Estimated Equipment Cost

Approximate Lease Start Date

Is the Equipment New or Used? Select...NewUsed

Lease Term Requested* Select...12 months24 months36 months48 months60 monthsUnknown

Due at End of Lease* Select...$1.00FMV10%Unknown

Additional Information

Additional instructions, comments, questions

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