Name of Lessee (Firm or Individual): *

Federal I.D. Number (Firm): *

Business Telephone Number: *

Previous Business Office Address:

Street:

City:

State/Prov:

Zip:

Number of years at previous address: *

Reason for leaving above address: *

Office Contact (regarding lease and rent matters): *

Emergency Contact (when office contact is unavailable): *

To assist the U.S. Postal Service, please list the names of all individuals, firms, corporations or partnerships what would be receiving mail at your address: *

Please note below how you would like your name/company to appear on the Directory Board located in the lobby: *

The following information must be completed in full. All information will be held in strict confidence

Type of Organization *

 Corporation  Partnership  Individual

Nature of Business: *

Years in Business: *

Number of Employees: *

Principal Owners of Business

Owner #1 Name (first and last): *

Owner #1 Address:

Street:

City:

State/Prov:

Zip:

Owner #1 Telephone Number: *

Owner #2 Name (first and last):

Owner #2 Address:

Street:

City:

State/Prov:

Zip:

Owner #2 Telephone Number:

Owner #3 Name (first and last):

Owner #3 Address:

Street:

City:

State/Prov:

Zip:

Owner #3 Telephone Number:

Owner #4 Name (first and last):

Owner #4 Address:

Street:

City:

State/Prov:

Zip:

Owner #4 Telephone Number:

Bank References

List only name, address and type of account. DO NOT INCLUDE ACCOUNT NUMBERS!

Bank #1 Name: *

Bank #1 Phone: *

Bank #1 Address:

Street:

City:

State/Prov:

Zip:

Type of account (checking, savings, credit, etc.): *

Bank #2 Name:

Bank #2 Phone:

Bank #2 Address:

Street:

City:

State/Prov:

Zip:

Type of account (checking, savings, credit, etc.):

Credit References (4 required)

Reference #1 Name: *

Reference #1 Address:

Street:

City:

State/Prov:

Zip:

Reference #1 Telephone Number: *

Reference #2 Name: *

Reference #2 Address:

Street:

City:

State/Prov:

Zip:

Reference #2 Telephone Number: *

Reference #3 Name: *

Reference #3 Address:

Street:

City:

State/Prov:

Zip:

Reference #3 Telephone Number: *

Reference #4 Name: *

Reference #4 Address:

Street:

City:

State/Prov:

Zip:

Reference #4 Telephone Number: *

I (we) certify that all the information on this application is correct, and that I (we) fully understand your credit terms with respect to payment of the monthly rent and other charges. I (we) hereby agree to pay any service or interest charges that accure due to late payment of rent and/or other charges.

I (we) authorize you to obtain additional information through personal interviews with anyone acquainted with my business or any of its principals. This inquiry may include information as to the character, general reputation, personal characteristics and mode of living of any of hte pricipals of the business. I (we) reserve the right to make a written request within 90 days to receive detailed information about the nature and scope of the additional information obtained.

Name of Individual Completing this Form: *

Title of Individual Completing this Form: *