Coin-O-Matic.com - Coin Store Laundry

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EQUIPMENT

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FINANCING

CAREER OPPORTUNITIES

COIN STORE LAUNDRY

Financing

Borrower/Lessee
Company Name:
D/B/A: (Doing Business As)
Address:
City, State & Zip:
Telephone: xxx-xxx-xxxx
Contact Name:
Direct Line: xxx-xxx-xxxx
e-Mail:
Fax: xxx-xxx-xxxx
Fed Tax ID: xx-xxxxxxx
D&B #: (Dun & Bradstreet)
State of Incorporation / Organization:
Website:
Business Description:

Time in Business (Years):
Type of Business:	S-Corp LLC Proprietorship Partnership C-Corp Non-profit

Whirlpool/Maytag Distributor
Company Name:
Address:
City, State & Zip:
Telephone: xxx-xxx-xxxx
Fax: xxx-xxx-xxxx
Contact:
e-Mail:

Bank Reference
Principal Bank:
Account Number:
Telephone: xxx-xxx-xxxx
Contact:

Additional Comments

Personal Information on Officers, Partners or Owners
Name:
Home Address:
City, State & Zip:
Telephone: xxx-xxx-xxxx
Social Security #: xxx-xx-xxxx
% Ownership:


Name:
Home Address:
City, State & Zip:
Telephone: xxx-xxx-xxxx
Social Security #: xxx-xx-xxxx
% Ownership:

Trade References
Company Name:
Telephone: xxx-xxx-xxxx
Contact:


Company Name:
Telephone: xxx-xxx-xxxx
Contact:

New Equipment to be financed

Address of Installation:

Qtity	Model	Description	Serial Number(s)	Purchase Price (w/o tax)

Proposed Finance Terms

Number of Months
(Installment Loan or Lease):

Financing type:
Installment Loan
Lease

If leasing, Lease Purchase Option $1 or FMV:

* Complete financial statements may be required for all transactions exceeding $100,000.

I hereby represent all information is true, correct and complete. By placing my/our full name and date of birth in the indicated boxes you affirm your signature to be acceptable as a written signature. I/we authorize the release of any credit information, business or personal to be released to the submitter or its assigns. Submitter complies with section 326 of the US Patriot Act. This law mandates that submitter or its assigns request and verifies certain information about you and your company. A copy or fax of this authorization shall be valid as the original.

Electronic Signature #1:	Date of Birth:	Title:	Date:

(Type Authorizing Officer Name)	(MM/DD/YYYY)		(MM/DD/YYYY)


Electronic Signature #2:	Date of Birth:	Title:	Date:

(Type Authorizing Officer Name)	(MM/DD/YYYY)		(MM/DD/YYYY)

Or you can download to fax:
COIN-O-MATIC, INC.
Executive Offices – 3950 NW 31 Avenue
Miami, Florida 33142
Fax: (305) 635-1118 or (407) 240-3131