Horwith Freightliner, Northampton PA.

CREDIT APPLICATION

Please print, fill out and fax to 610-261-2916

Purchaser: ______________________________________  Phone:  (     ) ____________________
Address:   ____________________________________________
City:___________________________ County:_________________ State:________  Zip:_______
CUSTOMER INFORMATION:

checkbox.gif (867 bytes)   Partnership              checkbox.gif (867 bytes) Proprietorship         checkbox.gif (867 bytes) Nonprofit Org          checkbox.gif (867 bytes)  Corporation

 Date of Birth:____________ Social Security No.:_________________ Years at Present Address:______
 
Previous Address:
Street: __________________________________________________ Since:__________________
City: __________________________________  State: ________________ Zip: ______________
______________________________________________________________________________
Street: __________________________________________________ Since:__________________
City: __________________________________  State: ________________ Zip: ______________
Home of Principal:
checkbox.gif (867 bytes) Own / Buying checkbox.gif (867 bytes) Renting checkbox.gif (867 bytes) Mobile Home checkbox.gif (867 bytes) Live with Relatives
 
SPOUSE INFORMATION:
Date of Birth: _____________________   Social Security No. ______________________
Employer:__________________________________________  Phone: (____)___________
Time on Job ( _______Years  _______ Months )     Annual Income: ______________________
EMPLOYMENT INFORMATION:
Truck (s) to be operated for: ____________________________________________________
Contact:  _________________________________    Phone  (____)________________________
Employed: (________Years ______Months )  Type of contract:   checkbox.gif (867 bytes)Written      checkbox.gif (867 bytes)     Oral
Total Years in Trucking: _____ No. of Trucks Owned: ________    No. of Trucks Leased: ________
Type of Use: __________________________________________________
Commercial Drivers Licence # : ______________________  Expires: _________________
PREVIOUS EMPLOYMENT:
Company: ________________________________________________________
Contact: ______________________________   Phone: ________________________________
Employed: (________Years ______Months )    Occupation: ____________________________
Company: ________________________________________________________
Contact: ______________________________   Phone: ________________________________
Employed: (________Years ______Months )    Occupation: ____________________________

FINANCIAL INFORMATION:
References ( relatives or friends not living with you ):
Name City,State Phone Relationship
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Bank/Mortgage Company References:
Bank Name Contact Phone City State Complete Acct. #
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Equipment Financing and Leasing References*:
Bank/Finance Co.

Contact

Phone

City

State

Account Numbers

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
______________________________________________________________________________
* Include paid out creditors if this information is available
Legal Actions:

Prior Bankruptcy:

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YES

checkbox.gif (867 bytes)

NO

Judgments:

checkbox.gif (867 bytes)

YES

checkbox.gif (867 bytes)

NO

Tax Liens:

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YES

check box (867 bytes)

NO

Lawsuits Pending:

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YES

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NO
 
SIGNATURE
For the purposes of procuring and maintaining credit, the undersigned submits the foregoing statement and information, including any supplemental sheets, as being a full, true and correct statement of my/our financial condition on the date stated. The undersigned agrees to notify Lender immediately in writing of any material unfavorable changes in financial condition. We hereby grant permission to all above creditors to release our account information to Lender.
Please attach year-end financial statements for the past two years and current prior month-end financial statements. Financial statements should be balance sheet, profit and loss statement, and statement of cash flows.

Signature: ________________________________________
Title ( if applicable ) _______________________   Date: __________________

HORWITH FREIGHTLINER, Northampton PA

CREDIT APPLICATION

Please print, fill out and fax to 610-261-2916