| Applicant Information |
| First Name: | | |
| Last Name: | | |
| E-mail Address: | | |
| Company: | | |
| Address: | | |
| City: | | |
| State: | | |
| Zip: | | |
| How Long At Address: | | |
| Own Or Rent: | | |
| Mortgage/Rent Paid To: | | |
| Prior Address: | | |
| Prior City: | | |
| Prior State: | | |
| Prior Zip: | | |
| Business Phone: | | |
| Evening Phone: | | |
| Cell Phone: | | |
| Fax: | | |
| Date of Birth: | | |
| Age: | | |
| Social Security Number: | | |
| Number of Dependents: | | |
| Spouse Full Name: | | |
| Spouse Birth Date: | | |
| Spouse Age: | | |
| Spouse SSN: | | |
| Applicant: | | |
| Corporate Tax ID: | | Only if Corporation |
| License Number: | | Include State and Expiration Date |
| About The Driver |
| Purchaser to Drive: |
| |
| Driver's Name: | | |
| Driver's Date of Birth: | | |
| Driver's License Number: | | |
| Corporate Information (If Corporation) |
| Corporation Name: | | |
| State Incorporated: | | |
| Date of Incorporation: | | |
| Date In Business: | | |
| Principal 1 Full Name: | | |
| Title: | | |
| Age: | | |
| Ownership %: | | |
| Principal 2 Full Name: | | |
| Title: | | |
| Age: | | |
| Ownership %: | | |
| Nearest Relatives Not At Address Above |
| Name 1: | | |
| Address: | | |
| City: | | |
| State: | | |
| Phone: | | |
| Relationship: | | |
| Name 2: | | |
| Address: | | |
| City: | | |
| State: | | |
| Phone: | | |
| Relationship: | | |
| Name 3: | | |
| Address: | | |
| City: | | |
| State: | | |
| Phone: | | |
| Relationship: | | |
| Name 4: | | |
| Address: | | |
| City: | | |
| State: | | |
| Phone: | | |
| Relationship: | | |
| Employment History Last 5 Years |
| Company Name 1: | | |
| Contact Name: | | |
| Contact Phone: | | |
| Address: | | |
| Your Position: | | |
| How Long: | | |
| Company Name 2: | | |
| Contact Name: | | |
| Contact Phone: | | |
| Address: | | |
| Your Position: | | |
| How Long: | | |
| Company Name 3: | | |
| Contact Name: | | |
| Contact Phone: | | |
| Address: | | |
| Your Position: | | |
| How Long: | | |
| How Long As Owner/Operator: | | |
| Nature of Business: | | Materials, Between What Points, Construction, Over-The-Road, Etc |
| Monthly Income: | | |
| Trade In Description |
| Year: | | |
| Make: | | |
| Model: | | |
| Body Style/Type: | | |
| Engine: | | |
| Transmission: | | |
| Rears: | | |
| Serial Number: | | |
| Sleeper: | | |
| Tractor Package: | | |
| Other Info: | | |
| Title State: | | |
| Months In Loan: | | |
| Payment Amount: | | |
| Amount Still Owed: | | |
| Financial and Credit Statement |
Be sure to include all assets including real estate, savings accounts, trucks, trailers, automobiles and loans and all liabilities including credit cards, fuel bills, etc. |
| Description 1: | | Savings |
| Bank: | | First Bank |
| Phone: | | (123)123-1234 |
| Account Number: | | 12341234 |
| Asset Value: | | 6400 |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 2: | | Checking Account |
| Bank: | | First Bank |
| Phone: | | (123)123-1234 |
| Account Number: | | 12341234 |
| Asset Value: | | 3200 |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 3: | | 99 Ford Explorer |
| Bank: | | ABC Bank |
| Phone: | | (800)123-1234 |
| Account Number: | | 1234512345 |
| Asset Value: | | 18000 |
| Payment Amount: | | 510 |
| Amount Owed: | | 14000 |
| Description 4: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 5: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 6: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 7: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 8: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 9: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 10: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 11: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 12: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 13: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 14: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Description 15: | | |
| Bank: | | |
| Phone: | | |
| Account Number: | | |
| Asset Value: | | |
| Payment Amount: | | |
| Amount Owed: | | |
| Final Questions |
| Bankruptcy Within 10 Years: |
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| Any Items Repossessed: |
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| Signature |
The information given above is true and complete. Lender may receive from and disclose to other persons, including credit reporting agencies, information about Applicant's accounts and credit experience and Applicant authorizes any person to release to Lender credit experience and account information on Applicant. This shall be a continuing authorization for all present and future disclosures of account information and credit experience on Applicant made by Lender or any person requested to release such information to Lender. |
| Signed: | | March 10th, 2010 |
| E-mail Address: | | |
