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• Who is submitting the request?

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• Submitted By Company Name *
• Submitted By Contact Name *
• Submitted By Email Address *
• Submitted By Phone Number *
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• Who is financing for?

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• Company Name *
• Contact Name *
• Mailing Address *
• City *
• State *
• Alabama Alaska Alberta Arizona Arkansas British Columbia British Virgin Islands California Canada Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Mexico Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Nova Scotia Nunavut NW Territories Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Isl Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands (US) Virginia Washington West Virginia Wisconsin Wyoming Yukon
• Province/Territory *
• Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• Postal Code *
• Email Address *
• Local Phone Number (not toll-free) *
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• Contract Terms:

• Equipment Description *
• Total Financed Amount *
• Desired Finance Term *
• 12 24 36 39 48 60 63 72
• Desired Purchase Option *
• FMV $1 EFA SFA
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• Comments:

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• Send a copy of this application:

• Email Address
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• For Vendors requesting credit on behalf of an end user:

• By submitting this application, Vendor, by and through the representative of Vendor who is transmitting this application, hereby represents to Account Services Processing Center (“Account Services”) that: (1) all information contained in the above referenced application is true and correct to the best of Vendor’s knowledge, (2) in the event Vendor later discovers that any of the above information is not correct, Vendor will submit to Account Services a new application with the correct information, (3) Vendor is submitting the above application on behalf of the credit applicant named above (the “Applicant”) with the express permission, and at the express direction, of the Applicant for the purpose of obtaining commercial credit, (4) the Applicant and the individual listed above under Owner Information (“Owner”) have each expressly authorized Vendor and Account Services to investigate the financial responsibility of Applicant, and/or Owner, and to obtain information from any credit reporting agency relating to Applicant and/or Owner in connection with Account Services extending credit to Applicant and/or reviewing/collecting the account.
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• For end user customers requesting credit:

• The individual submitting this application hereby (i) certifies that the information provided above is correct and complete and (ii) authorizes Account Services Processing Center (“Account Services”), or its designee(s), to investigate the financial responsibility of the business listed above (“Applicant”), and/or the individual listed above under Owner Information (“Owner”), and to obtain information from any credit reporting agency relating to Applicant and/or Owner in connection with Account Services extending credit to Applicant and/or reviewing/collecting the account. IF YOUR APPLICATION FOR BUSINESS CREDIT IS DENIED, YOU HAVE THE RIGHT TO A WRITTEN STATEMENT OF THE SPECIFIC REASONS FOR THE DENIAL. TO OBTAIN THE STATEMENT, PLEASE CONTACT GREATAMERICA FINANCIAL SERVICES CORPORATION, 625 FIRST ST SE, CEDAR RAPIDS, IOWA 52401 (319-365-8000) WITHIN 60 DAYS FROM THE DATE YOU ARE NOTIFIED OF OUR DECISION. WE WILL SEND YOU A WRITTEN STATEMENT OF REASONS FOR THE DENIAL WITHIN 30 DAYS OF RECEIVING YOUR REQUEST FOR THE STATEMENT. THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT PROHIBITS CREDITORS FROM DISCRIMINATING AGAINST CREDIT APPLICANTS ON THE BASIS OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, MARITAL STATUS, AGE (PROVIDED THE APPLICANT HAS THE CAPACITY TO ENTER INTO A BINDING CONTRACT); IF ALL OR PART OF THE APPLICANT’S INCOME IS DERIVED FROM ANY PUBLIC ASSISTANCE PROGRAM; OR IF THE APPLICANT HAS IN GOOD FAITH EXERCISED ANY RIGHT UNDER THE CONSUMER CREDIT PROTECTION ACT. THE FEDERAL AGENCY THAT ADMINISTERS COMPLIANCE WITH THIS LAW CONCERNING THIS CREDITOR IS THE FEDERAL TRADE COMMISSION, EQUAL CREDIT OPPORTUNITY, WASHINGTON, D.C. 20580.
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