Nextran Corporation Buyer's Credit Application
Telephone - 678-420-2352 Fax - 678-420-2395
Credit Application For: Truck Purchase Parts and/or Service
Borrower is: Individual DBA Propritorship Year Started Yr Incorp
(Check one) Partnership Corp S-Corp
Name of Borrower Date of Birth Soc. Sec. or Fed. Tax ID
Address Phone Number CDL#/State or State Tax ID
City / State / Zip If Individual - Work Phone
Co-Owner Name (If Applicable)/ or Corporate Officer. Social Security Number
Address City / State / Zip
Applicant to Operate Vehicle New Equipment Purpose: Fleet Size - Current
Yes No Replacement Expansion # Trucks # Trailers
Material to be hauled Average Monthly Mileage Gross Monthly Income Prev. Year Gross Income
Additional Income Information Source: Gross Monthly Income Prev. Year Gross Income
CREDIT REFERENCES
Bank Name City Account Number Contact Phone
checking savings
Truck Finance Ref City Account Number Contact Phone
Truck Finance Ref City Account Number Contact Phone
Trade Ref(12,000+) City Goods Purchased Contact Phone
Trade Ref($12,000+) City Goods Purchased Contact Phone
HAULING REFERENCES / WORK SOURCES (not required for parts/service application)
1. Company Hauling For (Current) City How Long? Contact Phone
1. Company Hauling For (previous) City How Long? Contact Phone
1. Company Hauling For (New Haul) City How Long? Contact Phone
PERSONAL INFORMATION
Own Home Outright Living With Parents
Buying Home Leasing/Renting years lived there months Mo. Pmnt
Ever Been Bankrupt? Ever had a repossession? Taxes currently past due?
Yes No Yes No Yes No
For the purpose of securing credit from you, I certify that the above information is true and complete to the best of my knowledge. NEXTRAN CORPORATION may receive from and disclose to other persons, including reporting agencies, information about my accounts and credit experience and I hereby authorize any person to release to NEXTRAN CORPORATION my credit experience and account information. This shall be a continuing authorization for all present and future disclosures of account information and credit experience made by NEXTRAN CORPORATION or any other person requested to release such information to NEXTRAN CORPORATION.
Applicant Signature and Title Applicant Signature and Title