Credit Application

Your Leasing Contact is:
Reggie Brown
Allstate Capital, LLC
1600 S Federal Highway, Suite
Pompano Beach, FL 33062
Phone: 954-934-0438 x213
Fax: 303-479-2333
reggieb@allstatecapital.com
www.allstatecapital.com
Vendor Contact is:
Ali Netupsky
MuscleDriver USA, LLC
587 Greenway Industrial Drive
Fort Mill, SC 29708
Phone: 803-835-6875
ali@muscledriverusa.com
www.muscledriverusa.com

Please fill out this form and press the "Submit" button.  If your browser does not support forms, please print out this form , fill it out and fax it to our 24 hour fax at 954-725-2746.   Thank you!
Vendor Information
 (seller of equipment)
Vendor Name
Vendor Address
City, State, Zip  
select
 
Contact
Vendor Telephone
x
Vendor Fax
x
 
Lessee Company Information  (company entering into credit agreement)
Exact Legal Business Name  
Doing Business As
Business Mailing Address  
City, State, Zip  
select
 
   
Equipment Location     
City, State, Zip  
select
 
   
Equipment Location is
select
 
Business Telephone
x  
Business Fax
x
Nature of Business  
Business Start Date
(under current ownership)
Business Start Date
(any ownership)
Type of Business
select
 
Federal Tax ID Number
Dun & Bradstreet Number
Own or Rent Business Location? |
 
Officer, Partner or Guarantor Information
Principal 1 is signer.
Please review credit criteria for credit descriptions.
Principal 1 Name (First M Last Sfx)    
Home Address  
City, State, Zip  
select
 
   
Home Phone
x
Cell Phone
x
Email Address
Title
select
Own Home or Rent? |
Biz Ownership %  
Social Security Number  
Primary Contact Name (if different)
Phone Number
x
Email Address
 
Business Bank References
 
Name of Business Bank 1
Account Number
Age of Bank Account
select
Exact Name on Business Account
Contact Officer
Officer Phone
Approximate Average Bank Balance
select
Any NSF/OD's in Last 12 Months?

|

 
Quote
 
Term (Number of Months)

select
Total Equipment Cost  
Equipment Description  
Age of Equipment

select
Submitted By



Special Program Request
(Must be Approved)
select
How did you hear about us?
 
Miscellaneous / Other Info
Enter any comments or suggestions below:s below:

Please review the following terms and conditions and then check "I Agree":  
By submitting an online Lease Application to Allstate Capital, LLC, applicant:

1.    represents that all information provided in the application is true, accurate and complete;

2.    represents that the applicant is, in fact, the individual as to whom such information pertains or an authorized individual as to the business entity or other person to which or whom such information pertains;

3.    represents that the applicant is 18 years of age or older;

4.    represents that the applicant expressly authorized Allstate Capital, or its representative(s) to obtain credit reports on the applicant, the business entity (or other person(s) referenced in the application) making an application from any source including credit bureau reporting agencies and such person's bank for use in evaluating such application;

5.    represents that the applicant expressly authorized the release of business and/or personal credit information to Allstate Capital, any purchaser of Allstate Capital's interest in this application and any resulting agreement between applicant and Allstate Capital, and/or credit reporting agency;

6.    represents that the transaction is intended solely for business or commercial purposes;

7.    agrees that if you have asked that a message regarding the status of the application be e-mailed (or faxed) to you, you represent that the applicant expressly authorized Allstate Capital, its assigns, and its representative(s) to transmit such a message, whether favorable or unfavorable, to the e-mail address (or fax number) you have provided; and

8.    represents that the applicant expressly authorized Allstate capital to execute and file any UCC financing statement in the customer's name upon approval of the application. Please retain a copy of this application for your records.

Applicant hereby acknowledges that its use of this website may cause information to be accessible to unintended third parties. Applicant acknowledges and agrees that it understands that information may be available to unauthorized third parties, and it fully releases Allstate Capital from any liability therefore, and applicant expressly waives any rights to any direct, indirect, incidental, consequential or punitive damages arising out of the application.

Applicant hereby agrees that a photostatic or electronic copy of this application shall be as valid as the original. Applicant represents and warrants that he or she is authorized to execute this authorization and release regarding credit information on behalf of Applicant and any other person(s) described in the application.

Please retain a copy of this notice for your records.

The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract), because all or part of the applicant's income derives from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law is the Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580.

If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please mail any such requests to Allstate Capital at 3665 Park Central Blvd N, Pompano Beach, FL 33064 within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement.

I/we agree that any security deposit is not refundable unless the application is rejected by Allstate Capital. Furthermore, it is understood that Allstate Capital reserves the right to reverse any credit decision if the information contained herein is found to be incorrect, or if any approval expires due to no fault of Allstate Capital, and I/we will indemnify Allstate Capital, or its assigns, for any and all costs incurred with this application for credit including any cost incurred in the placement or reservation of the intended leased equipment based on the information contained herein. Allstate Capital reserves the right to retain, or bill for, a reasonable processing fee if this lease application is approved and not accepted by the applicant.

Only check "I Agree" and press "Submit" below if you agree to all of these terms and conditions.
I Agree By checking this check box and by submitting this application, the parties listed above authorize Allstate Capital, and/or its assigns, to pull credit and perform all due diligence required in considering this transaction and I/we have read, understand, and agree to the additional terms and conditions listed above and to our fair credit reporting practices.