FMI Freightliner

FMI Freightliner

CREDIT APPLICATION

Application Type

Partnership Proprietorship Nonprofit Org. Corporation

Corporation Tax ID Number, if applicable

Personal Information

Primary Applicant

Full Name

License No.

(With State + Expiration Date)

Date Of Birth

Age

S.S. Number

No. Dependents

Business Phone

Residence Phone

Spouse

Full Name

Date Of Birth

Age

S.S. Number

Present Address

Address

City-State-ZIP

How long?

Years & Months

Own/Rent

Own Rent

Mortgage/Rent Paid To

Former Address

Address

City-State-ZIP

Corporate Information

Corporation Name

Incorporated in what state?

Date Of Incorporation

Date In Business

Principal

Age

Principal Title

% Owned

Principal

Age

Principal Title

% Owned

Nearest Relatives Not At Above Address

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 Income

Purchaser's Financial & Current Credit Statement

Examples: How To Fill Out This Section

Include: Assets - Real Estate, Savings Account, Trucks, Trailers, Autos, Loans Liabilities - Credit Cards, Fuel Bill, Etc.
Description	Bank	Phone	Acct. No.	Asset Value	Payment Amount	Amount You Owe

Have you filed bankruptcy in the last 10 years?

Yes No

Any items repossessed?

Yes No

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	Your Title
	Your E-mail Address

Disclaimer: "E-mail is not considered to be a completely secure medium for the transmission of sensitive information. Those who e-mail credit application information do so at their own risk."