Nextran Corporation
Buyer's Credit Application
Telephone - 800-347-6225 Fax - 904-633-9280
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
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