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Information with asterisks (*) is required. There is no obligation to apply.

COMPANY INFORMATION
*Legal Company Name:   *Phone:      
*Street Address:   Alternate Phone :    
*City:   Fax :    
*State:   *Company structure:
*Zip Code:   *No. of Years in Business:
Web Site :   *Federal Tax ID Number (EIN):

PERSONAL INFORMATION ON OFFICERS, PARTNERS OR GUARANTORS
*Name (Owner #1):   Name (Owner #2) :
*Title:   Title :
*Home Address:   Home Address :
*City:   City :
*State:   State :
*Zip Code:   Zip Code :
*Social Security Number:       Social Security Number :    
*Email Address:   Email Address :

EQUIPMENT DESCRIPTION
*Description:
*Equipment Cost:$ Lease Terms (No. of Yeas) :   New Used
*Vendor: Contact Name :
*Phone:       Estimated date of purchase:

DECLARATION
The above information, together with any accompanying financial statements, schedules, or other materials, is submitted for the purpose of obtaining credit and is warranted to be true, correct and complete. Hampton Ridge Financial is hereby authorized to investigate (directly or through an agent or nominee) our credit and financial responsibility. By signing below, the undersigned individual, who is either a principal of the credit applicant or a personal guarantor of its obligations, provides written instruction to Hampton Ridge Financial or its designee authorizing review of his/her personal credit profile from a national credit bureau. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for the purposes of update, renewal, or extension of such credit or additional credit and for reviewing or collecting the resulting account. A photostat or facsimile copy of this authorization shall be valid as the original. By signature below, I/we affirm my/our identity as the respective individual(s) identified in the above application. I/we confirm that no petition for bankruptcy has been filed under the company or on an individual basis and that no open liens/judgments exist against the company or on an individual basis.
USE OF YOUR PERSONAL INFORMATION 
Hampton Ridge Financial collects and uses your personal information to operate and improve its site and deliver the services or carry out the transactions you have requested. We user the information we collect to provide the service your request, to inform you of other products or services offered by Hampton Ridge Financial and its affiliates, and to send you relevant information related to Hampton Ridge Financial services. We do not sell, rent, or lease our customer lists to third parties.

You can stop the delivery of future promotional e-mail from Hampton Ridge Financial sites and service by following specific instruction in the e-mail you receive.
 YES I AGREE THAT THE INFORMATION I AM SUBMITTING IS TRUE AND CORRECT AND AGREE WITH THE TERMS IN THE ABOVE DECLARATION.
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