Credit Application Form

PERSONAL INFORMATION
FIRST NAME   MIDDLE INITIAL LAST NAME SUFFIX DATE OF APPLICATION
SOCIAL SECURITY NUMBER
(Format: 123456789)
CDL NO. YRS. CDL DATE OF BIRTH (mm/dd/yyyy) MARITAL STATUS NO. OF DEPENDENTS


ADDRESS       CITY   COUNTY   STATE   ZIP
HOME PHONE     CELL PHONE   EMAIL ADDRESS      
- -

MORTGAGE COMPANY OR LANDLORD NAME PHONE NUMBER   HOW LONG? YRS/MOS YEARS IN AREA
- /
FORMER ADDRESS (IF LESS THAN FIVE YEARS),CITY,STATE, ZIP CODE HOW LONG? YRS / MOS
/
BUSINESS NAME BUSINESS TAX I.D. NUMBER
BUSINESS ADDRESS (IF DIFFERENT FROM ABOVE) BUSINESS PHONE NUMBER
-
HAVE YOU EVER TAKEN BANKRUPTCY?
ARE YOU SUBJECT TO ANY TAX LIENS?
ARE YOU A DEFENDANT IN ANY LEGAL ACTION?
HAVE YOU EVER HAD ANY ITEM REPOSSESSED?
EXPLANATION (Less than 200 characters):      
LIST OF RELATIVES
FIRST AND LAST NAME   CITY/STATE   PHONE NUMBER RELATIONSHIP
/ -
FIRST AND LAST NAME   CITY/STATE   PHONE NUMBER RELATIONSHIP
/ -
FIRST AND LAST NAME   CITY/STATE   PHONE NUMBER RELATIONSHIP
/ -
SPOUSE INFORMATION
APPLICANT'S EMPLOYMENT HISTORY FOR PAST FIVE YEARS
CURRENT EMPLOYER   PHONE NUMBER   POSITION   HOW LONG? YRS/MOS
- /
IMMEDIATE PAST EMPLOYER   PHONE NUMBER   POSITION   HOW LONG? YRS/MOS
- /
OTHER PREVIOUS EMPLOYER   PHONE NUMBER   POSITION   HOW LONG? YRS/MOS
- /
 TRUCK OWNERSHIP AND USAGE
PREVIOUS TRUCK OWNER?    
IF FINANCED, NAME OF LENDER(S) IS THE APPLICANT THE DRIVER?
CURRENT #: PREVIOUS #:
TRUCK TO HAUL FOR (DO NOT LIST OWN COMPANY) CONTACT PHONE NUMBER  
COMPANY NAME CITY STATE
-
ADDITIONAL HAUL (IF APPLICABLE) CONTACT PHONE NUMBER  
COMPANY NAME CITY STATE
-
BALANCE SHEET
ASSETS (What you own) LIABILITIES (What you owe)
ACCOUNTS RECEIVABLE $ TOTAL OWING ON CREDIT CARDS $
    AMOUNTS OWING TO RELATIVES & EMPLOYERS $
LIST TRUCKS & TRAILERS OWNED   LIST NAMES OF LENDERS ON TRUCKS & TRAILERS  
Item Name: $ Item Name: $
Item Name: $ Item Name: $
Item Name: $ Item Name: $
Item Name: $ Item Name: $
Item Name: $ Item Name: $
REAL ESTATE OWNED (RESIDENCE FIRST, THEN OTHERS)   MORTGAGE LENDERS ON REAL ESTATE OWNED    
Item Name: $ Item Name: $
Item Name: $ Item Name: $
PERSONAL VEHICLES OWNED     LIST NAMES OF LENDERS ON PERSONAL VEHICLES  
Item Name: $ Item Name: $
Item Name: $ Item Name: $
Item Name: $ Item Name: $
OTHER ASSETS (ITEMIZE)     OTHER DEBTS (ITEMIZE)        
Item Name: $ Item Name: $
Item Name: $ Item Name: $
Item Name: $ Item Name: $
TOTAL ASSETS: $ TOTAL LIABILITIES: $
ESTIMATED INCOME STATEMENT
TIME PERIOD GROSS TRUCKING INCOME OTHER INCOME DEDUCTIONS & EXPENSES OPERATING PROFIT
$ $ $ $
CREDIT REFERENCES:    CITY/STATE     ACCOUNT NUMBER   PHONE NUMBER
/ -
/ -
/ -
BANK ACCOUNT INFORMATION:OUNT   CITY/STATE     ACCOUNT NUMBER   PHONE NUMBER
/ -
/ -
/ -


For purposes of establishing and maintaining credit, the undersigned submits the foregoing statement and information contained on this form, 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 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 Transport Funding, LLC, or its agents and assigns to inquire into, and receive any information concerning my character, reputation, personal characteristics, mode of living, and all information from creditors which Transport Funding, LLC deems relevant for granting and collection of the proposed borrowing. This authorization shall be effective from the date which this application is signed and is extinguished automatically upon payment of the present borrowing, if any is granted.

The undersigned expressly authorizes any person, including but not limited to federal and state agencies or any of their vendors or contractors, to release to Transport Funding, L.L.C., or its agents, any information, including but not limited to the undersigned’s driver and safety inspection history, vehicle accident reports, driving violations and driver status, credit experience and account information, about me. The undersigned acknowledges and consents to Transport Funding L.L.C., and/or any of its agents monitoring and recording telephone calls, regardless of which party initiates the call.

I further represent that neither the undersigned, any principal officer of 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.

           
  Customer Name (Format: FirstName LastName Suffix) Spouse Name (Format: FirstName LastName)