BUSINESS
INFORMATION (If Applicable)
Business Name
Business Type
(Individual, Partnership,
Corporation)
Location Address
Mailing Address
City
State
Zip
Phone
FAX
E-Mail
Personal Information
First Name
Middle Initial
Last Name
Social Security Number
Date of Birth
Marital Status
Spouse Name
Spouse Social Security #
Street Address
Mailing Address
City
State/Province
Zip/Postal Code
Phone
Country
Homeowner
Time There in Years
Time In The Area in Years
Work Phone
Home Phone
Cell Phone
E-mail
Previous Address
City
State/Province
Zip
Time There, In Years
Nearest Relative
(Not living with you)
Address
City
State
Phone Number
Relationship
EMPLOYMENT
INFORMATION
First Time Owner/Operator?
Years as Owner/Operator
Time as Driver - Years
Number of Trucks Owned
Number of Trailers Owned
Reason for Application
(Additional Unit or
Replacement)
Buy to Drive
(Yes or No)
Company to Work For
Phone Number
How Long There, Years
Position Held
Previous Employer
Phone Number
How Long There, Years
Position Held
Previous Employer
Phone Number
How Long There, Years
Position Held
FINANCIAL
INFORMATION
Name of Bank
Branch Address
City
State
Zip
Contact
Phone Number
Previous Truck Credit With
Phone Number
Year & Make of Truck
Date Paid Off
Previous Truck Credit With
Phone Number
Year & Make of Truck
Date Paid Off
Have you ever declared
bankruptcy? (yes or no)
If Yes, Explain
Are you a defendant in a legal
action? (yes or no)
If Yes, Explain
Have you ever had a Repo?
(yes or no)
If Yes, Explain
Other information you think
will help expedite your application.
You also authorize B.W. Crisman & Co., Inc. and the
lender to 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. By submitting this form
you certify that the information is true and complete.
