HOLTEC USA CUSTOMER APPLICATION

Secure Finance Application

COMPANY INFORMATION SECTION:
Legal Company Name
This question is required
Company DBA Name If Applicable?
Company Address?
Street*
City/Suburb
State*
Zip/Post Code*
Country*
This question is required
Phone Number?
This question is required
Email?
Please enter a valid email
Company Start Date?
/
/
Type of Business?
Select...
This question is required
Company Website
Tax ID/EIN #

OWNERSHIP SECTION:
Owner #1 First Name?
This question is required
Owner #1 Last Name?
This question is required
Owner #1 Home Address?
Street*
City/Suburb
State*
Zip/Post Code*
Country*
This question is required
Owner #1 Social Security Number
This question is required
Owner #1 Percentage Ownership
This question is required

Owner #2 First Name (If Applicable)?
Owner #2 Last Name (If Applicable)?
Owner #2 Home Address (If Applicable)?
Street
City/Suburb
State
Zip/Post Code
Country
Owner #2 Social Security Number (If Applicable)
Owner #2 Percentage Ownership (If Applicable)

EQUIPMENT AND VENDOR SECTION:
Equipment Seller Name
Holtec USA
Holtec USA
Description of Equipment
This question is required
Estimated Purchase Price
This question is required
Would you like any additional amount approved for additional equipment? If so, please state how much and for what.

AUTHORIZATION:
Signed Authorization
By Signing the below box, each undersigned individual, who is either a Principal of the credit applicant listed above or a personal guarantor of its obligations, provides written consent to Patriot Equipment Funding, LLC or its designee (assignee), to authorize review of his or her personal credit bureau.
Sign here
  
This question is required
By Signing the below box, each undersigned individual, who is either a Principal of the credit applicant listed above or a personal guarantor of its obligations, provides written consent to Patriot Equipment Funding, LLC or its designee (assignee), to authorize review of his or her personal credit bureau.
Submit

ANY QUESTIONS ON FINANCING YOUR HOLTEC USA EQUIPMENT PLEASE CONTACT OUR FINANCE EXPERT, DREW KABO, AT 215-327-8908 OR VIA EMAIL AT DREW@PATRIOTEQUIPMENTFUNDING.COM