Stillwater Leasing
Broker/Vendor Application

General Business Information * required
Legal Business Name *
Doing Business As (DBA)
Federal Tax ID
Company Phone *
Current Address *
City *
State/Province *
Zip/Postal Code *
Year Established *
Contact Email Address *
Business Website Address *
State Where Your Business is Registered *
Business Structure *
 
Do you have multi-state, national, or international locations? *
Ownership Information * required
Ownership/Principal Name *
Ownership/Principal Title *
Phone *
Ownership Address *
Ownership % *
State *
Ownership Information * required
Ownership/Principal Name *
Ownership/Principal Title *
Phone *
Ownership Address *
Ownership % *
City *
State *
Zip/Postal Code *
Vendor Equipment Information
 * required
Primary Equipment Type *
Authorized Distributor *
Manufacturer *
Do You Sell Used Equipment? *
Comments
Authorization, Representations and Warranties  
I hearby authorize and consent to Stillwater Leasing Company LLC (hereinafter SWL) and affiliates investigating and/or obtaining credit reports, trade references and information regarding this application and resulting accounts. If personal information has been provided, SWL has the right to obtain personal credit reports in connection with my request for this new account, or when SWL reviews my account.

Under penalties of perjury, I certify that: 1.) the Taxpayer Identification Number (TIN) provided on this form is correct; 2.) I am not subject to backup withholding due to failure to report interest and dividend income; 3.) I am at least 18 years of age; and 4.) I am a U.S. citizen or permanent resident alien.

(The I.R.S does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.)
Authorization required
By checking this box, each undersigned individual(s), who is either a principal of the credit applicant listed below or a personal guarantor of its obligations, provides written instruction to Stillwater Leasing, LLC or its designee (and any assignee or potential assignee thereof) authorizing review of his or her personal credit profile from a national credit bureau. Such authorization shall extend to obtaining a credit profile in considering the application of the credit applicant and subsequently for the purpose of update, renewal or extension of such credit and for reviewing or collecting the resulting account. A photostatic or facsimile copy of this authorization shall be as valid as the original.
Name of Person Submitting this form *
  Form Verification
Please type in the text you see above. This is used to verify the contents of this form.


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