EQUIPMENT TO BE LEASEDDescription *ELOG 2 year SolutionELOG 3 year solutionNumber of Units *Monthly Cost / Unit including data (plus applicable taxes)$Monthly Cost / Unit including data (plus applicable taxes)$Monthly Cost / Unit including data (plus applicable taxes)$Monthly Cost / Unit including data (plus applicable taxes)$Monthly Cost / Unit including data (plus applicable taxes)$Monthly Cost / Unit including data (plus applicable taxes)$Pricing For <10 Units$Pricing For 10-50 Units$Pricing For >50 Units$Required Installation Date *APPLICANT INFORMATIONBUSINESS INFORMATIONFull Legal Name *Operating As (trade name)# of EmployeesSelect One *Please select an optionCorporationSole ProprietorshipPartnershipDate of Incorporation *Have you been in business for less than 5 years? *YesNoOWNER INFORMATIONHome Address Owner 1 *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Name of Owner 1 *Date of Birth Owner 1 *SECOND OWNER INFORMATIONName of Owner 2 *Date of Birth Owner 2 *Home Address Owner 2 *Apartment, suite, etcCity *ZIP / Postal Code *BUSINESS INFORMATIONThese units are forStreet Number (# only) *Street Name *Suite No.City *Select Province/State *Select Province/StateAlbertaBritish ColumbiaSaskatchewanManitobaOntarioQuebecNewfoundlandPrince Edward IslandNova ScotiaNew BrunswickYukonNorthwestNunavutPostal/Zip *Select Country *Select CountryCanadaUnited StatesWebsite *Email Address *Phone *CellContactType of Hauling *Geography *RegionalInterprovincialCanadaNorth AmericaBank *Branch *How Long? *Account #Any comments or questions?The undersigned certifies the above information to be true and correct. By signing below, I consent and authorize the following entities: Prime Capital Group Inc., Xpedite Leasing Inc., and 941315 Alberta Ltd., (collectively known as Prime Capital Group) and its representatives, and any potential credit grantor assignee, 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, leasing brokers, on an on-going basis) any of my credit, financial, and personal information that Prime or its agents or affiliates deems necessary to complete, service or enforce any lease, ancillary deed or transaction, including but not limited to assignments and securitizations. We acknowledge that you or your financing partners may transfer and store information to jurisdictions where you or your financing partners do business. As a result, information may be accessible to regulatory authorities in accordance with the laws of these jurisdictions. 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 fax 1-780-437-7268 (Attn: Privacy Office) or mail #215, 625 Parsons Road SW Edmonton AB T6X 0N9 Attn: Privacy Office.Electronic Acknowledgment (Applicant) *I, the Applicant, certify the above to be correct and I authorize Prime Capital Group to process my information.Electronic Acknowledgment (Company Principal) *I, the Company Principal, certify the above to be correct and I authorize Prime Capital Group to process my information. Submit ApplicationPlease do not fill in this field.
