Midwest Alchemist Online Application

Credit Processing Center
Tel: (800)866-5335 Fax: (800)866-8174

For immediate lease review for approval, submit this form online. All fields marked with an asterisk (*) are required.

Lessee Information
* First Name:
* Last Name:
* Company:
* Address 1:
Address 2:
* City:
* State/Prov.:
* Zip:
* Country:
* Phone (W):
Phone (H):
Phone (C):
Fax:
* E-mail:
Company Information
Type of Business:	Start-Up Existing Business
Years:	(in business)
Employees:	(number)
Square Feet:	(of business)
The following information is required for us to process your application.
General Information
Cost:	$ (of equipment)
Location:	(of equipment)
Equipment Desired:
When do you plan on buying?:	Today Within 30 days Within 60 days Within 90 days Other
Comments:
Business Bank References
Bank/Branch:
Account #:	(checking)
Opened:	(date)
Bank Phone:
Trade References (suppliers currently used in business)
Name:
Account #:
Phone:
Personal Information (owners/partners)
First Name:
Last Name:
Title:
SS#
Date of Birth
Address 1:
Address 2:
City:
State/Prov.:
Zip:
First Name:
Last Name:
Title:
SS#
Date of Birth
Address 1:
Address 2:
City:
State/Prov.:
Zip:

Authorization
USA Credit Authorization: You hereby certify: (i) the information provided above is true and correct, (ii) you authorize us, our affiliates and any third parties acting for us or on our behalf, including Midwest Alchemist (hereinafter collectively "US", "WE", or "OUR") to investigate all bank, credit, and trade references, and said references are hereby authorized to release any requested information to US or OUR nominee, (iii) such authorization shall extend to obtaining a credit profile in considering this application and subsequently for the purposes of update, renewal, or extension of such credit or additional credit and for reviewing or collecting the resulting account, (iv) this information may be transmitted by you to US and by US to OUR underwriter(s) for the purpose of granting to you credit, either electronically or manually, and that by submitting this application, you take full responsibility for transmission thereof, (v) You are over 18 years of age, (vi) You acknowledge your rights under the Fair Credit Opportunity Act, and (vii) this request is for business and not consumer purposes.

If your application is approved, you authorize US to collect, hold, use, exchange and disclose your personal information, as required, in order to administer your contract, determine your insurance eligibility, and secure the assets being financed, or as required or permitted by law, You also authorize US to use your personal information for internal statistical analysis purposes. WE will keep a file containing some or all of your personal information at 3275 Intertech Drive, Suite 100, Brookfield, WI 53045 from time to time. You have a general right to access and rectify the personal information in this file by making a written request to the above address, Attention: Privacy Office.