Personal Information
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First Name:
Last Name:
M.I.: |
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Social Security Number:
Date of Birth:
Marital Status: |
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No. of Dependents:
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Address:
County: |
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City:
State:
Zip Code: |
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How Long? |
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Phone Number:
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Former Address (five year minimum):
How Long?
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Business Name:
Tax I.D. Number:
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Business Address ( If different from above):
Business Phone No.: |
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Employment History For Past Five Years (Present or Last Employer First)
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Name and Address of Company |
Phone No. |
Position |
How Long? |
| 1 |
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| 2 |
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| 3 |
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Complete this
section only if this is a joint application with your spouse, or if you are
relying on your spouses income or assets as a basis for repayment of the credit
requested, of if you reside in community property state.
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Spouse's Name:(First, MI, Last):
Social Securty No:
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Date of Birth:
Spouse's Employer:
Position Held:
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How Long?
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Nearest relative not living with you:
Relationship: |
Have you ever filed bankruptcy?
Are you a Defendant in any legal action?
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| Have you ever had any item repossessed?
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If you have answered "Yes" to any questions above, please explain below: |
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Truck Usage
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How long as owner/operator?
Operator license No:
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Purchaser to drive?
If No, please provide driver's name:
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Driver's Name (First, MI, Last)
Address:
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Years of Experience:
Operator License No:
State & Date:
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Social Securtiy Number:
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Truck to work for - Company Name:
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| Address: |
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Credit References
(Please provide tractor, trailer, mortgage credit references)
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For the purpose of establishing and
maintaining credit, the undersigned submits the foregoing statement and
information contained on this sheet, both written and printed, and including
supplemental sheets, if any, as being a full true, and correct statement of my
financial condition and all above matters on the date stated. The undersigned
agrees to notify you immediately in writing of any materially unfavorable
change in my financial condition or the above matters and in the absence of
such notice or of a new and full written statement all matters herein may be
considered as a continuing statement and substantially correct. The undersigned
hereby authorizes inquiries into, to request, and to recieve any information
concerning my character, general reputation personal characteristics, mode of
living, and all information from creditors which deems relevant for the
granting and collection of the proposed borrowing. This authorization shall be
effective from the date upon which this application is signed as is
extinguished automatically upon full payment of the present borrowing, if any
is granted. Upon my written request, additional information as to the scope of
this inquiry, if one is made, will be provided
I further represent that neither the undersigned, any principal officer of the
undersigned nor any contemplated operator of any equipment proposed to be
purchased has any record or reputation of having violated any federal or state
laws relating to liquor, narcotics or contraband; and no such person has been
convicted of any felony.
I understand that the financial company and/or seller of motor vehicle parts or
services to whom this application is presented, will be relying on the accuracy
of the matters set forth herein as a basis for extending any credit which I may
receive.
Signature:
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Date:
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