Financing Application Financing Application Legal Business Name * Time in Business Type of Business Tax I.D. Number Business Address City State / Region Phone Number E-mail Address Web Address Name of Owner Last Name of Owner Home Address City State / Region Social Security Number Percentage of Ownership Name of Co-Owner (if applicable) Last Name of Co-Owner Home Address City State / Region Postal / Zip Code Country United States Social Security Number Percentage of Ownership Equipment Description & Cost Term(s) Requested (months) By submitting this Application, the applicant consents to Laser Service Solutions (“LSS”) releasing all information & data provided to a third party partner for the purpose of a business credit check. The applicant represents that this Application is for credit for business purposes only and all information provided with this Application is true and correct, and hereby authorizes LSS and its designee, assigns or potential assigns and its and their affiliates or any lending source to whom this application is submitted (collectively, Creditors) to obtain from credit bureaus and other third parties, and share, information any of them deems necessary to arrive at a decision regarding this Application, including credit and criminal background checks. By submitting this Application, the applicant and undersigned individual(s) as principal of and/or guarantor for the applicant, authorizes all such Creditors to review and share its/his/her personal credit profile provided by a national credit bureau in considering this Application and for the purpose of update, renewal, or extension of credit to the Applicant or the collection of any resultant accounts. Additionally, this authorization permits Creditors to share and exchange information and to request, obtain and review bank, financial or other information from past, present or potential Creditors. I authorize all deposit, borrowing, financial and trade information to be released by telephone or fax. A photocopy or fax of this authorization shall be valid as the original. To help fight terrorism and money laundering, Federal Law requires banks to verify the information you provide, which may include drivers license or other documents, to identify you. If you are human, leave this field blank. Submit Δ