| *Company
|
DBA |
|
| *FED. TAX I. D.
NO. (or SS# if SOLE) |
TAX EXEMPT? No Yes (Provide a copy of certificate.) |
| *ADDRESS
|
ADDRESS 2 |
|
|
*CITY |
*STATE |
*ZIP |
|
SHIP TO ADDRESS (if different from above) |
||
|
ADDRESS |
ADDRESS 2 |
|
|
CITY |
STATE |
ZIP |
| COMPANY CONTACT |
| *FIRST NAME |
*LAST NAME |
|
TITLE |
*EMAIL (if any) |
|
*PHONE |
FAX |
|
Check one for
Notification of Credit Decision Fax Phone E-mail |
|
| STRUCTURE OF
ORGANIZATION: |
STATE OF
ORGANIZATION |
|
| TYPE
OF BUSINESS |
YRS.
IN BUSINESS |
|
| YRS. UNDER
PRESENT CONTROL |
||
|
D. & B. NO. |
||
| MIAMI BUSINESS TELEPHONE ACCOUNT MANAGER (if known) | ||
| FIRST NAME |
LAST NAME |
|
| TITLE |
||
| CREDIT REQUIRED | ||||||
|
||||||
| PRINCIPAL'S
FIRST NAME(1) |
PRINCIPAL'S LAST
NAME(1) |
SOCIAL SECURITY
NO.(1) |
| HOME PHONE
|
% OWNERSHIP
|
TITLE |
| ADDRESS
|
ADDRESS |
|
| CITY |
STATE |
ZIP |
|
||
| PRINCIPAL'S
FIRST NAME(2) |
PRINCIPAL'S LAST
NAME(2) |
SOCIAL SECURITY
NO.(2) |
| HOME PHONE
|
% OWNERSHIP
|
TITLE |
| ADDRESS
|
ADDRESS |
|
| CITY |
STATE |
ZIP |
|
||
AUTHORIZATION
AND ACKNOWLEDGEMENT  I hereby certify that all information contained in this application
and all attachments hereto is true and complete to the best of my
knowledge, and has been supplied for the purpose of obtaining credit
in the form of an equipment lease. I authorize Miami Business
Telephone, Inc to verify any and all of the information with the
source(s) it deems appropriate and further authorize any of the
above banks and trade references to release requested information to
Miami Business Telephone, Inc. I understand that this constitutes an
application only and shall not bind either Miami Business Telephone,
Inc or the applicant in relation to the proposed lease transaction.
|