Rental - Lease
Application

Rental-Lease Application

Application Type

Corporate Tax ID / FEIN *

U.S. Department of Transportation Number *

MC # *

Nature of Business *

Information On Company

Is company tax-exempt? *

YES - I will upload tax-exempt on Your Website. in the Field Below.
YES - I will fax my tax-exempt status to 812-284-8364.
NO

Mileage per week? *

Type of goods hauled? *

3rd Party Hauler *

Haul for Self? *

Have you filed bankruptcy in the last 10 years? *

Any items repossessed? *

Company's Financial and Current Credit Statement

Your company may be required to provide Two (2) Years' worth of financial statements in addition to this application. *

I understand that Century NationaLease may require additional financial information and is willing to provide this information at a future date as part of the application and approval process.

Trade References (One of Three Required)

Applicant must provide a business reference to qualify for Rental / Leasing at Century NationaLease. Personal references are not acceptable.

Trade Reference 1 - Business Name *

Trade Reference 1 - Accounts Receivable Contact

Trade Reference 1 - Address *

Address Line 1

Address Line 2

City

State

Zip Code

Trade Reference 1 - Email *

Confirm Email

Trade Reference 1 - Phone Number *

Trade Reference 1 - Fax Number

Trade Reference 1 - Best way to contact? *

Email
Phone

Trade Reference (Two of Three Required)

Applicant must provide a business reference to qualify for Rental / Leasing at Century NationaLease. Personal references are not acceptable.

Trade Reference 2 - Business Name *

Trade Reference 2 - Accounts Receivable Contact

Trade Reference 2 - Address *

Address Line 1

Address Line 2

City

State

Zip Code

Trade Reference 2 - Phone Number *

Trade Reference 2 - Fax Number

Trade Reference 2 - Email *

Confirm Email

Trade Reference 2 - Best way to contact? *

Email
Phone

Trade Reference (Three of Three Required)

Applicant must provide a business reference to qualify for Rental / Leasing at Century NationaLease. Personal references are not acceptable.

Trade Reference 3 - Business Name *

Trade Reference 3 - Accounts Receivable Contact

Trade Reference 3 - Address *

Address Line 1

Address Line 2

City

State

Zip Code

Trade Reference 3 - Phone Number *

Trade Reference 3 - Fax Number

Trade Reference 3 - Email *

Confirm Email

Trade Reference 3 - Best way to contact? *

Email
Phone

Insurance Requirements

The customer above will be/is contract leasing or renting our equipment.

We cannot release any vehicle without evidence of current primary coverage.

The three required insurance documents are indicated as "REQUIRED":

REQUIRED - 30 Day Notice Of Cancellation

REQUIRED - Liability-requested CSL-Combined Single Limits: $1,000,000.00

CENTURY LEASING, LLC MUST BE NAMED AS ADDITIONAL INSURED

REQUIRED - Physical Damage, Maximum deductible: $5,000.00

CENTURY LEASING, LLC MUST BE NAMED AS LOSS PAYEE.

Certificate must include the following wording:

Century Leasing, LLC is added as additional insured and loss payee with respect to all vehicles
leased or rented to the insured.

Certificate must show: Policy number, coverage, limits, expiration dates, etc. Scheduled auto policies may require certain information in regards to the unit being leased/rented. Please let us know if you will need any unit specific information in regards to the rental truck.

You can submit this information in three ways:

Upload documents in the provided field below online.
Email to support@centurynationalease.com
Fax to (812) 284-8364.

REQUIRED - 30 Notice of Cancellation *

I will provide 30 Day Notice of Cancellation of Insurance to Century NationaLease or provide update insurance information as part of being able to rent or lease from Century NationaLease.

REQUIRED - Liability-requested CSL-Combined Single Limits: $1,000,000.00 *

I will provide certificate of insurance showing Century Leasing, LLC as ADDITIONAL INSSURED AND LOSS PAYEE with respect to all vehicles leased or rented to the insured company.

REQUIRED - Physical Damage, Maximum Deductible: $5,000.

I will provide certificate of insurance showing Century NationaLease Physical Damage, Maximum Deductible is $5,000

NOTIFICATION OF ACCIDENT OR DAMAGE TO RENTED OR LEASED VEHICLE *

I will provide notification to Century NationaLease about any accident or damage to the rented or lease vehicle in 24-hours.

Upload Insurance Documents Here or Fax as stated above.

Click or drag files to this area to upload. You can upload up to 4 files.

I (Applicant) understand and agree that you, (Century NationaLease, successors and assigns) may communicate the information contained herein to others to decide whether or not to extend credit. I authorize the above bank and business references, as well as any of my lessors, landlords and any other past or present creditors to supply any and all necessary information to you which will assist you in your credit inquiry. This application is given for the purpose of obtaining credit. I hereby authorize you to obtain one or more reports regarding Applicant from credit reporting agencies in connection with the Application, and to gather and use, from time to time, any and all financial and/or credit information relating to the undersigned. I hereby certify under penalty of law that the information supplied in connection with this Application is true and correct, and that I understand and acknowledge your credit terms. In the event of any material change in Applicant’s financial condition, I will notify you immediately in writing. Applicant agrees to pay 1.5% per annum interest on all invoices more than 30 days past due, and Applicant also agrees that Applicant is liable to you for payment of attorney's fees and costs that may be incurred by you in the collection of any and all obligations of the Applicant at any time owed to you and grants to you a security interest in all equipment, inventory, accounts, and general intangibles to secure all obligations.

SIGN and DATE

Signature *

Printed Name *

Your Title *

Signed Date *

Rental - Lease
Application