Leasco, Inc.
2565 St. Mary’s Ave
Omaha, NE 68105

Credit Application Form

Personal Information

1. Name(Required)

First Last

2. Address(Required)

Street Address Apartment or Suite# City State ZIP Code

3. Date of Birth(Required)

4. Social Security Number(Required)

5. Primary Phone(Required)

6. Secondary Phone

7. Email(Required)

Equipment Information

8. # of Trailers(Required)

Select the number of trailers you are interested in leasing

9. Type(s) of Trailer(s)(Required)

Sand

Cement

Crude

Flatbed

Select the type(s) of trailer(s) you are interested in leasing (can select multiple)

Business Information

If you own a company, please fill out the fields below. If you do not own a company, please skip to section 13.

10. Business Name

11. DBA if Applicable

12. Physical Address

Street Address Apartment or Suite# City State / Province / Region ZIP / Postal Code

13. Have you filed Bankruptcy before?(Required)

Yes

14. Have you ever defaulted in payment of credit before?(Required)

Yes

16. Personal References

Reference 1 Name

Reference 1 Address

Reference 1 Phone

Reference 1 Email

Reference 2 Name

Reference 2 Address

Reference 2 Phone

Reference 2 Email

17. ID Verification

ID Verification(Required)

Drop files here or

Max. file size: 300 MB.

Please upload front and back copy of your ID

Signature(Required)

Date(Required)

Please enter today's date.

By submitting this application, you authorize Leasco and its affiliates to obtain credit reports in connection with this request for credit and any update, increase, renewal, extension, or collection of the credit received. You understand that Leasco will rely on the information in this application and on your credit report to make its decision.

Credit Application Form

Personal Information

Equipment Information

Business Information

16. Personal References

17. ID Verification

Services

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