Lease or Time-Payment Request Form Leasing Order Please note. Leasing or Time Payment is approved on a case by case basis. Requesting a Lease or Time Payment does not guarantee approval. Organization Requesting Lease or Time PaymentName of Organization* Company Website Name of Person Placing Order* First Last I am an authorized representative of my company with the authority to request this lease or time payment.* Yes No I further agree that in the event that a payment is missed the Meridian DPA device and all peripherals will be returned within 30 days in good condition or I will be liable for the full cost of the machine and any legal fees involved in the collection process.Address Where The Devices Will Be Located* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Shipping Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (If different to address where devices will be located)Phone*Email* I Am Requesting Lease Time Payment Custom Payment Plan Number of Units Requested*OneTwoThreeFourFiveSixSevenEightNineTen Δ