The Wirt-Rivette Group

Apply Now Online!

This lease application will be transmitted to The Wirt-Rivette Group. If you are not comfortable sending personal information via the internet, we invite you to download our printable application which you may then mail or fax to us.

Our goal is to respond to you within 48 hours, during regular business hours. All email correspondence is completely confidential. The Wirt-Rivette Group customers may also use our toll free telephone support center to contact a service representative during regular business hours: 800.777.9478.

Online Lease Application Form:

Please fill out any information that is applicable or relevant to your lease request.

Lessee Company Information

Legal Business Name
Phone Number
Fax Number
Cell Number
Contact Name
Nature of Business
Address
City
State
Zip
E-mail
Authorized Signer
Title
Type of Business
Date Established
Tax Exempt
If Exempt, Why?

Owners or Officers

Name		Name
Title		Title
Home Phone		Home Phone
Home Address		Home Address
City		City
State		State
Zip		Zip
Employer		Employer
Time Employed		Time Employed
Income/Year		Income/Year
Own or Rent?		Own or Rent?
Monthly Expenses		Monthly Expenses

Company Bank Reference

Bank Name or Branch
Relationship in Years
Chkg/Loan Acct #
Bank Telephone
Bank Contact

Company Trade References

Name		Name
Address		Address
Phone Number		Phone Number
Fax Number		Fax Number
Contact		Contact
Acct #		Acct #

Vendor and Equipment Information

Vendor Name/Contact
Vendor Address
Vendor City
Vendor State
Vendor Zip
Telephone
Fax
Vendor Guaranty?
Equipment Cost
Term (Months)
Equipment Description and Intended Use
Equipment Location

Enter any additional comments or information that could be useful in the space provided below:

I Certify that all information above is accurate and complete and authorize Wirt Financial Services, Inc. and/or it's assignees to obtain financial reports from any lending institution or credit reporting bureau at any time.