Business Details
Full Legal Name:
DBA/Operating As:
Business Registration Type: Corporate Partnership Sole Proprietor
In Business since:
Address Incl. Postal Code:
Business Premises: Owned Leased
Primary Contact:
Work #:
Nature of Business:
Total Number of Employees:
Application Details
Full Legal Name:
Date of Birth:
Email Address:
Mobile Phone:
Same as Business Address
Street Address including Postal Code:
How Long at Current Address:
Own or Rent: Own Rent
Marital Status:
Have you ever filed for bankruptcy?: Yes No
If Yes, when?:
Present Employer:
Start Date:
Business Ownership Percentage:
Industry Experience (Years):
Co-Applicant Details
Full Legal Name:
Date of Birth:
Email Address:
Mobile Phone:
Present Employer:
Start Date:
Gross Annual Income:
Relationship to Applicant:
Financial Information
Value of Real Estate: $
Mortgage Balance: $
Total Savings & Investment: $
Credit Card Debt/Balances: $
Other Personal Assets (excluding home): $
Loans and LOC: $
Personal Gross Annual Income: $
Company Gross Annual Income: $
Company Net Annual Income: $
Expected Additional Monthly Income from Equipment Purchase: $
Equipment to be Leased / Financed
Reason for Equipment Acquisition:
Equipment Description; Year:
Additional Equipment Details
New or Used: New Used
Price: $
Down Payment: $
Additional Comments
The undersigned certifies the above information and any information provided in the application and or Appendix A to be true and correct. Appendix A refers to any information provided, collected and or attached to complete this application. By signing below, I consent and authorize Quip Finance (“Quip”) and its Lenders and representatives, at any time to obtain on an on-going basis, verify, use, communicate with and disclose to third parties (including credit reporting agencies, credit exchanges, lenders, leasing brokers, and credit grantors, on an on-going basis) any of my credit, financial, and personal information that Quip deems necessary to complete, service or enforce any lease, ancillary deed or transaction, including but not limited to assignments and securitizations. You authorize us to collect, hold, exchange and disclose your personal information as requested in order to administer your contract & determine your insurance eligibility as required or permitted by law. You also authorize us to use your personal information for internal statistical analysis purposes. If you would like to review your own personal information, correct or revise existing information, have any questions, concerns or comments regarding its application please email (Attn: Privacy Office) or mail 201-23160 96th Ave, Langley BC V1M2S2 Attn: Privacy Office.

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