Company Name

Corporation   Partnership   Proprietorship    Tax ID Number

Contact

Phone Fax Cell

Street Address

City   State   Zip

Nature of Business Years in Business

PERSONAL INFORMATION

(Officer 1)

Name

Home Phone Fax Cell

Street Address

City   State   Zip

(Officer 2)

Name

Home Phone Fax Cell

Street Address

City   State   Zip

ACCOUNTANT / INSURANCE INFORMATION

Accountant   Insurance Co.

Contact                  Contact

Phone                           Phone

BANK INFORMATION

Name

Address

Contact Phone

Account Number

TRADE REFERENCES (Please use Finance Companies if Possible)

Name Account Number

Name Account Number

Name Account Number

VENDOR / DEALER INFORMATION

Name

Address

Contact Phone

Equipment Description

PRICE INFORMATION

Cost Trade Tax

Balance Term

Advanced Payments Purchase Option

Signature______________________________________________________________

I hereby authorize the release of the information to PCCI and warrant the truth and accuracy of the above.

(Please sign above when printing this form and faxing to us.)