| Name |
|
| Street Address |
|
| Address (cont.) |
|
| City |
|
| State/Province |
|
| Zip/Postal Code |
|
| Country |
|
| Home Phone |
|
| Pager Number |
|
| FAX |
|
| E-mail Address |
|
| Date of Birth |
|
| Social Security Number |
|
| Drivers License Number |
|
| State |
|
| Expiration Date |
|
| HazMat Endorsement |
|
| Number of years OTR: |
|
| OTR Miles: |
|
| DUI or Felony / YR of Offense: |
|
| In the past 3 years Number of
Speeding Tickets |
|
| Number of Moving Violations |
|
| Number of Accidents |
|
| Did you attend Truck Driving School |
|
| Where and how many weeks |
|
| Other License # and State |
|
| Marital Status |
|
| Wife or Significant Others Name |
|
| Are they employed |
|
| Their Monthly Income |
|
| # of Children at Home |
|
| Monthly Child Support |
|
| TOTAL MONTHLY EXPENSES |
|
| Do you Own or Rent |
|
| Monthly Rental/Mortgage Amount |
|
| Landlord/Mortgage Co Name |
|
| Their Address |
|
| Their Phone Number |
|
| Savings Bank Name |
|
| Account Number |
|
| Phone Number |
|
| Checking Bank Name |
|
| Account Number |
|
| Phone Number |
|
| Previous Address (last 5 years) |
|
| Previous Address (last 5 years) |
|
| REFERENCE #1 Name,Phone,Relationship |
|
| REFERENCE #2 Name,Phone,Relationship |
|
| Relative NOT Living with
you,Phone,Relationship |
|
| Work History past 10 years
Dates,Employer,Phone# |
|
| Dates,Employer,Phone# |
|
| Dates,Employer,Phone# |
|
| Dates,Employer,Phone# |
|
| Dates,Employer,Phone# |
|
| Dates,Employer,Phone# |
|
| Dates,Employer,Phone# |
|
| Dates,Employer,Phone# |
|
| Dates,Employer,Phone# |
|
| Dates,Employer,Phone# |
|
| ******Where did you hear about us |
|
| Are you interested in a truck
purchase? |
|
| Describe the truck you want. |
|
| What price do you want to pay? |
|
| Do you Have a Trade? |
|
| Describe your trade |
|
| Payoff on Trade |
|
| Where trade is financed? |
|
| Do you prefer a lease purchase? |
|
This
report is prepared under the Fair Credit Reporting Act (FCRA)
guidelines. I have the right to make a written request to
Truck Tech Inc, and the company Truck Tech has contracted me with,
to release the nature and substance of all information in its files
on me at that time, including the source of information. By
submitting this application, I hereby consent to your obtaining the
above information from DAC, and other services with the agreement
that such information which Truck Tech has or obtains, including my
business history with Truck Tech if accepted, may be supplied to
other companies. |