Financing | Clean Aid Services

Company Name*

Have you ever declared bankruptcy?*

Date*

Federal Tax Number*

Contact Name*

Street Address*

Apt, Suit, Bldg (optional)

City*

State*

Zip Code*

Country*

Phone Number*

Email*

Fax Number

Date Business Started*

Bank Name*

Bank Contact Person*

Bank Account Number*

Number of Employees*

Type of Business*

Company Annual Sales

Your preferred equipment distributor*

Terms in Months*

Third Party Guarantor

First Name*

Middle Name*

Last Name*

Social Security Number*

Driver's License Number*

Birth Date*

Percentage of Ownership*

Street Address*

Zip Code*

Apt, Suite, Bldg

City

State*

Country*

Phone Number*

Cell Phone*

Fax Number

Email*

Time at previous address*

Employer Name*

Work Phone Number*

Monthly Salary / Wages*

Length of Employment / Years / Months*

Occupation*

Other Income / Source

Percentage of Ownership*

Time at Current Address*

Residential Status*

Rent / Mortgage Payment*

Previous Address if less than 2 years at current address

By checking the above box , the undersigned individual, who is either a principal of the credit applicant or a personal guarantor of its obligations, authorizes lessor and/or debtor and their affiliates, successors or its designee (and any assignee or potential assignee thereof) to obtain consumer credit reports relating to his/her individual credit history and/or credit worthiness. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for the purposes of update, renewal or extension of such credit or additional credit and for reviewing or collecting the resulting account. A Photostat or facsimile copy of this authorization shall be valid as the original. By signing below, I/we affirm my/our identity as the respective individual(s) identified in this application and I/we authorize you to contact us at any numbers provided.

Verification Code:
Please use this code to enter into the Verification Code input at the end of this form.

Verification Code*

Financing Application Form