Lance                

Approximate Cost $:                                                                                                                        

Name:                                                                                                                                                  

Years in Practice:                                                                                                                             

S.S.#:                                                                                                                                                     

Office

Street:                                                                                                                                            

City:                                                                  State:                                     Zip:                            

Phone # :                                                                                                                                             

    I authorize Lance Leasing Ltd. to verify any credit information from whatever source it deems appropriate and I further authorize

 our banks, trade references  and Financial institutions the right to release by telephone or fax all credit information.

X                                                                                                      

                                                     Signature