Municipal Marine Application

Municipality Business Information :

Legal Name of Municipality/ Obligor: *

Federal ID

Address

Address Line 1

City

State

Zip Code

County

Phone

Fax

Email

Confirm Email

Gross Annual Revenue

State Organization ID

Contact Name *

First

Last

Contact Title

Contact Phone *

Contact Email

Email

Confirm Email

Alternate Contact

First

Last

Alternate Contact Title

Alternate Contact Phone

Alternate Contact Email

Email

Confirm Email

Type of Municipality

Population

Households

Department/Agency

Fiscal Officer Name

First

Last

Fiscal Officeer Title

Fiscal Officer Phone

Fiscal Officer Fax

Date Municipality Entity Was Established

Does the obligor self-insure for property & liability insurance?

Yes
No

Within the current calendar year, we or will not issue $10,000,000 or more total debt including all bonds, loans and leases.

We Will
We Will Not

Equipment Information (Attach separate sheet if necessary)

Equipment Description

Manufacturer

Model

Year

Quantity

Equipment Cost $

Total Cost $

Equipment Location

Address Line 1

City

State

Zip Code

Equipment

Equipment is Additional
Equipment is Replacement
New
Used

Soft Costs Included?

Yes
No

Amount of soft costs included (shipping, software, and sales tax)

Buyout Included?

Yes
No

Amount of buyout included:

Describe the essential use of the equipment:

Is the project a building?

Yes
No

If yes, who owns the land?

What is the physical address of the new building/project?

Address Line 1

City

State

Zip Code

Lease Terms Desired:

Length of Lease Term

3 Years
4 Years
5 Years

Other

Payment Mode

Monthly
4 Quarterly
Semi-Annual
Annual

First Payment Due

Upon Delivery

Other

Other Requests/ Requirements:

Vendor Information (Attach separate sheet if necessary)

Vendor Company

Vendor Contact email

Email

Confirm Email

Vendor Contact Name

First

Last

Vendor Contact Phone

Vendor City

State

Zip