Lease or Time-Payment Request Form

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 Payment
Name 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 State ZIP Code
Shipping Address
Street Address Address Line 2 City 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*

Organization Requesting Lease or Time Payment