Application Type


Personal Information

Primary Applicant

First Name
Middle Name
Last Name
Email
License Number
License State
License Expiration Date
Date of Birth
Age
Social Securty Number
Number of Dependents
Business Phone
Residence Phone

Spouse

Full Name
Date of Birth
Age
Social Securty Number

Current Address

Address Line 1
Address Line 2
City
State
Zipcode
How Long? (years and months)
Own/Rent
Mortgage/Rent Paid To

Former Address

Address Line 1
Address Line 2
City
State
Zipcode

Corporation Information

Corporation Name
Incorporated in what state?
Date Of Incorporation
Principal
Principal Age
Principal Title
Principal % Owned
Principal 2
Principal 2 Age
Principal 2 Title
Principal 2 % Owned

Nearest Relatives not at Above Address

Name
Address
City
State
Phone
Relation

Name
Address
City
State
Phone
Relation

Name
Address
City
State
Phone
Relation

Name
Address
City
State
Phone
Relation

Employment - Past & Present - Five Years

Company Name
Contact Name
Phone
Address
Position
How Long?

Company Name
Contact Name
Phone
Address
Position
How Long?

Company Name
Contact Name
Phone
Address
Position
How Long?

How long as an owner/operator?
Nature of Business
(Materials, Between What Points,
Construction, Over-The-Road, Etc.)
Gross Monthly Incomce

Trade-in Description

Truck

Year
Make
Model
Engine
Transmission
Rears
Sleeper
Serial Number
Condition
Title State
Months in Loan
Payment Amount
Amount Still Owed
Other Info

Trailer

Year
Make
Model
Length
Width
Height
Serial Number
Condition
Title State
Months in Loan
Payment Amount
Amount Still Owed
Other Info

Purchase Item Description

Year
Make
Model
STK #
Truck/Trailer
Notes

Purchaser's Financial & Current Credit Statement

How To Fill Out This Section
Example:
  • Assets - Real Estate, Savings Account, Trucks, Trailers, Autos, Loans
  • Liabilities - Credit Cards, Fuel Bill, Etc.

Description
Bank
Phone
Account Number
Asset Value
Payment Amount
Ammount You Owe

Description
Bank
Phone
Account Number
Asset Value
Payment Amount
Ammount You Owe

Description
Bank
Phone
Account Number
Asset Value
Payment Amount
Ammount You Owe

Description
Bank
Phone
Account Number
Asset Value
Payment Amount
Ammount You Owe

Description
Bank
Phone
Account Number
Asset Value
Payment Amount
Ammount You Owe

Have you filed bankruptcy in the last 10 years?
Any items repossessed?

Sign & Date

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.

Today's Date
Signed By
Signed Title
Signed Email




SECURE SUBMISSION