Company Name *
Address *
City *	State *	Zip *
	State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NM NV NH NJ NY NC ND OH OK OR PA OR RI SC SD TN TX UT VT VA WA WV WI WY
Time In Business *	Phone *
Email Address *

Equipment *

Equipment Cost *

Estimate Date of Purchase (MM/DD/YYYY)*

Consent and Authorization for Credit Report: The undersigned Lessee (hereinafter "Lessee") expressly authorizes American Capital Group (hereinafter "ACG") to obtain, directly or through an agent or its assignees, the Lessee's credit, background, and financial responsibility reports ("Reports") from any appropriate Reporting Agency and understand that such Reports may be used by ACG in the determination of whether or not to enter into a lease with Lessee. Lessee understands that such investigations may include seeking information as to the background, credit and financial responsibility of Lessee's officers and principals, or any of them. Lessee understands and consents that its credit information may be transmitted via the Internet, that such information may be accessible by unintended 3rd parties, that it is being submitted at our own risk, and that Lessee waives any right to any punitive damages arising out of or associated with the transmission, interception, use or misuse of the application. Lessee may request the status of this application to be transmitted by electronic mail and Lessee expressly authorizes ACG or its nominee(s) to transmit such message to the electronic mail address, which Lessee may provide. Lessee hereby consents to allowing ACG to obtain any and all Reports from any and all appropriate Reporting Agencies and agrees that such information maintained by such Reporting Agencies will be supplied to ACG and/or any other companies which subscribe to said services. Lessee therefore authorizes the procurement of said Reports by ACG and, if Lessee enters into a lease agreement with ACG, Lessee understands that this authorization shall remain on file and shall serve as on-going authorization for ACG to procure additional Reports at any other time during the lease agreement.

I hereby AGREE to the Consent and Authorization for Credit Report above. *