EQUIPMENT TO BE LEASEDDescription (Include Year, Make, Model etc.) *Cost *Currency *Please select an optionCADUSDTerm (Months) *Please select an option24364860VendorRepresentative *Phone Number *APPLICANT INFORMATIONFull Legal Name *Operating As (trade name)Select One *Please select an optionCorporationSole ProprietorshipPartnership# of EmployeesHow long have you been in business?Select One3 years or less4 to 10 years11 to 20 years21 to 40 years41 + yearsStreet Address *Apartment, suite, etcCity *ZIP / Postal Code *Province/StateAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingWebsite *Email Address *Phone *CellContactNature of Business *Reason for Equipment *PRINCIPAL/PERSONAL INFORMATIONFull NameDate of Birth *SIN #Street AddressApartment, suite, etcCityZIP / Postal CodeProvince/StateAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingHow Long?Own/Rent?OwnRentValueMtg. BalanceHome PhonePrevious EmploymentHow Long?Bankruptcy?YesNoWhen?Bank *Branch *How Long? *Account #The undersigned certifies the above information to be true and correct. By signing below, I consent and authorize the following entities: Prime Capital Group Inc., Xpedite Leasing Inc., and 941315 Alberta Ltd., (collectively known as Prime Capital Group) and its representatives, and any potential credit grantor assignee, at any time to obtain on an on-going basis, verify use, communicate with and disclose to third parties (including credit reporting agencies, credit exchanges, leasing brokers, on an on-going basis) any of my credit, financial, and personal information that Prime or its agents or affiliates deems necessary to complete, service or enforce any lease, ancillary deed or transaction, including but not limited to assignments and securitizations. We acknowledge that you or your financing partners may transfer and store information to jurisdictions where you or your financing partners do business. As a result, information may be accessible to regulatory authorities in accordance with the laws of these jurisdictions. You authorize us to collect, hold, exchange and disclose your personal information as requested in order to administer your contract & determine your insurance eligibility as required or permitted by law. You also authorize us to use your personal information for internal statistical analysis purposes. If you would like to review your own personal information, correct or revise existing information, have any questions, concerns or comments regarding its application please fax 1-780-437-7268 (Attn: Privacy Office) or mail #215, 625 Parsons Road SW Edmonton AB T6X 0N9 Attn: Privacy Office.Electronic Acknowledgment (Applicant) *I, the Applicant, certify the above to be correct and I authorize Prime Capital Group to process my information.Electronic Acknowledgment (Company Principal) *I, the Company Principal, certify the above to be correct and I authorize Prime Capital Group to process my information. Submit ApplicationPlease do not fill in this field.
