SECTION 1 | BUSINESS INFORMATION

Legal Business Name *

DBA *

State Incorporated *

Time in Business *

Business Type *

Grower
Manufacturer
Dispensary
Laboratory

Business Address *

Address Line 1

City

State

Zip Code

TIN *

Business Phone *

Website *

Products Sold *

Cannabis
Hemp
Both

Production Facility Ownership *

Lease
Own

Rent/Mortgage Amount $ *

Additional Comments

Source

SECTION 2 | OWNERS/OFFICERS INFORMATION

For principal Officer/Primary Owner with Ownership >2%

Name *

Title *

Percentage of Ownership *

Business Address *

Address Line 1

City

State

Zip Code

Facility Ownership *

Own
Rent

Email Address *

Phone Number *

SSN *

DOB *

DL# *

State of Issuance *

SECTION 3 | REFERENCES

Bank Reference

(Previous bank if less than two years of history with current bank)

Bank Name *

Business Bank Account *

Checking
Savings

Bank Location *

Name on Bank Account *

Bank Account Number *

Routing Number (ABA) *

Trade Reference

Company *

Phone Number *

ELEVATED EQUIPMENT SUPPLY LEASING APPLICATION

SECTION 1 | BUSINESS INFORMATION

SECTION 2 | OWNERS/OFFICERS INFORMATION

SECTION 3 | REFERENCES