MedLease for medical, computer, software, and financing solutions



Lease Type:
Equipment Cost:	$
Desired Term:		Months
Expected Delivery Date:

About Dollar Buyout Lease

With this equipment lease financing option, at the end of your lease term you "buy" your equipment for just $1. This is an attractive option for companies that know their equipment will not lose value and are looking to keep their equipment at the end of the lease.



	Business Legal Name:		and DBA if applicable
	Street Address:
	City:
	State:
	Zip Code:
	Telephone:
	Email:
	Principal Contact:
	Type of Business:
	Federal Tax ID Number:
	Type of Legal Entity:
	Years in Business:

How We Process Your Information

Step 1
Please enter all information as accurately as possible. Please read and agree to all the terms at the bottom of the Application.

Step 2
Hit "Submit Application" - your application will be processed, please record your confirmation number. If you have any questions, please call us at (866) 476-8617. We are available 24 hours a day, 7 days per week.



	Equipment Description:
	Vendor Name:
	Vendor Contact:
	Vendor Phone Number:

Not sure where to find it?

Please be as accurate as possible. Accuracy will ensure a faster turn-around time. If possible, please provide us with the direct number for your vendor representative. This will allow us to contact them immediately upon approval.



	OFFICER 1
	Name and Title:
	Percent Ownership & SSN:
	Address, City, State, Zip:
	Home Phone Number:

	OFFICER 2
	Name and Title:
	Percent Ownership & SSN:
	Address, City, State, Zip:
	Home Phone Number:

	OFFICER 3
	Name and Title:
	Percent Ownership & SSN:
	Address, City, State, Zip:
	Home Phone Number:

Why This Information Is Important

MedLease will protect your personal privacy. We will never sell your personal information to anyone and will never individually identify you to third parties.

The personal information we are collecting is for application purposes only. We will keep this policy, as well as our privacy practices and systems, up to date.



	Name of Bank:
	Contact Name and Phone:
	Account Number:



	REFERENCE #1
	Name:
	Location:
	Phone Number:
	Account Number:

	REFERENCE #2
	Name:
	Location:
	Phone Number:
	Account Number:

	REFERENCE #3
	Name:
	Location:
	Phone Number:
	Account Number:

Who Makes Good Trade References?

Enter the name of your contact with the company, with whom we may discuss your trade reference. This includes banking accounts, checking and savings, investment banks, and/or anyone who has granted you a line of credit, or loan.



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Questions? Comments?

For immediate assistance you may reach us toll free at: 1 (866) 476 - 8617