* First
Name
* Middle
Initial
* Last
Name
* Street Address
* City
* State
Select State
AL
AZ
AR
CA
CO
CT
DE
DC
FL
GA
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
* Zip Code
* Home Phone
(No hyphen or dash)
Cell Number
(No hyphen or dash)
E-mail Address
* Date of
Birth (mm/dd/yy)
SS Number
No dashes
CDL Number
CDL State
Select State
AL
AZ
AR
CA
CO
CT
DE
DC
FL
GA
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
CDL Exp Date
(mm/yy) No hyphen or dashes
* Years OTR
OTR Miles
No commas
# of Speeding Tickets past 3 years
Select
0
1
2
3
4
5
Number of Accidents
Select
0
1
2
3
4
Driving
School
Name (If yes where)
Marital Status
Select
M
S
D
Spouse
or Significant Others Name
Are they employed
Select
YES
NO
Do you Own or Rent
Select
O
R
Monthly Rental/Mortgage Amount
Landlord/Mortgage Name
Savings
Name
Savings
Account Number
Checking Name
Checking
Account Number
* REFERENCE Name, Phone Relationship
REFERENCE
Name, Phone Relationship
* Relative (Not
Living with you)
/ Relationship
* Relative
Address
* Relative
Phone
Employment
History (5 years)
* Current
Employer
Dates
Name
and Phone #
Previous
Employer
Dates
Name
and Phone #
Previous
Employer
Dates
Name
and Phone #
Previous
Employer
Dates
Name
and Phone #
Where did
you
hear about us?
Name of
Salesman
if you've talked to
one before
This
report is prepared under the Fair Credit Reporting Act (FCRA)
guidelines. I have the right to make a written request to
Truck Discount Mart, Inc and the company Truck Discount Mart, Inc.
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 Discount Mart, Inc. has or obtains, including my business
history with Truck Discount Mart, Inc. if accepted, may be
supplied to other companies. I also agree to receive Truck
Discount Mart, Inc's inventory updates.