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Complete this form and then press the submit button on the bottom of the form, or print it off and then fax or send it for processing. We are usually able to get back to you with in 24 hours with approval. Click Here to Return to Previous Page

POS System LEASE / CREDIT APPLICATION

Attn: Douglas Ogden

PLEASE FAX OR SEND APPLICATION TO:

14 Hughes Suite B206 Irvine, CA 92618

Tel (800) 850-3101x229

Fax 847-663-7216

posi_lgo3.jpg (5058 bytes) bluedotlgo2.jpg (4686 bytes)

COMPANY INFORMATION

^{Legal
Company Name/ State Of Incorporation:} Tax ID #:

^{Company Address}

^City

^State

^Zip

^{Authorized Signer}

^Title

^Telephone

^{Business Structure}

^{No. of Years in Business}

^{Equipment Cost $: 5,000 or}

PERSONAL INFORMATION

^Name

^{Social Security #}

^{Ownership %}

^{Own/Rent Home}

^{Home Address}

^City

^State

^Zip

^{Home Phone Number}

^Name

^{Social Security #}

^{Ownership %}

^{Own/Rent Home}

^{Home Address}

^City

^State

^Zip

^{Home Phone Number}

BANK REFERENCES

^{Name of Bank / Branch}

^{How Long?}

^{Checking Acct. #}

^Telephone

^{Contact Officer}

^{Name of Bank / Branch}

^{How Long?}

^{Checking Acct. #}

^Telephone

^{Contact Officer}

TRADE REFERENCES

^{Name of Supplier}

^{Account Number}

^Telephone

^{Contact Person}

^{Name of Supplier}

^{Account Number}

^Telephone

^{Contact Person}

^{Name of Supplier}

^{Account Number}

^Telephone

^{Contact Person}

LEASE / LOAN REFERENCES

^{Name of Lender}

^{Original Amount}

^{Loan Acct. #}

^Telephone

^{Contact Person}

EQUIPMENT DESCRIPTION

Point-of-Sale System

DECLARATION

By signing below, the undersigned individual, who is either a principal of the credit applicant or a guarantor of it’s obligations, provides this written instruction to FirstCorp, it’s nominees or assigns, authorizing review of his/her personal credit profile from a national credit bureau. Such authorization shall extend to obtaining a credit profile in consideration of this application and subsequently for the purpose of update, renewal or the extension of such credit or additional credit and for reviewing and collecting the resulting account. A Photostat or facsimile copy of this authorization shall be valid as the original. By signature below, I/we affirm our identity as the respective individuals identified in the related application.

Applicant:

Email Add:

Signature :________________________________________

Title:

Date:

Please contact me as soon as possible regarding this matter.

Copyright © 2006 Point-of-Sale Systems.Com and FirstCorp Funding. All rights reserved. Revised: March 31, 2006 .

Copyright © 2006 Point-of-Sale Systems.Com and FirstCorp Funding. All rights reserved.
Revised: March 31, 2006 .