Company Name: Address: City: Materials Hauled: Description of Business: State: Zip:
Tax ID #:
Phone #:
Type of Entity(Proprietorship, Partnership, C Corp, S Corp): County: Years In Business: Number of Trucks in Fleet:
#Heavy
Date Incorporated & State: Years of Industry Experience # Employees:
# Med Duty
Important! Include credit references from current/past truck/trailer leases/loans in section below Lessor/Creditor/Trucks Phone Yr. Opened Orig. Bal. Curr. Bal. Payment
Equipment
Bank Name: Phone #: Ever Been Bankrupt? Yes No
Year Account Opened: Contact: Ever had a Repossession? Contact: Yes
Checking Account #: Line of Credit Limit: No
Checking Account Balance: Line of Credit Available: Yes No
Any taxes currently due? Phone #:
If Yes / Year: Required for Leasing - Insurance Carrier:
Majority Owner Name: Address: City: Current Residence? Own: Rent: Second Owner/Guarantor Name: Address: Name of Relative or acquaintance not residing with you: Address: State: Zip:
Percent Ownership: Home Phone: Monthly Income: Mortgage Holder:
Date of Birth: Social Security #: Monthly Housing Payment: Personal Net Worth: Date of Birth: State: Phone: State: Zip: Zip:
Time at Current Residence (yrs/mos):
YEARS: Months:
Social Security #: City: Relationship: City:
Please provide the following information on 3 current towing contracts.
Contract 1 Company Name Contact Phone
Contract 2
Contract 3
The information given above is true and complete. Miller Financial Services Group Inc. and its Assignees 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 Miller Financial Services Group Inc. and its Assignees 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 make by Miller Financial Services Group Inc. and its Assignees, or any person requested to release such information to Miller Financial Services Group Inc. and its Assignees. By typing in your name you also agree to these terms.
By: Dealer: Date/Time: Qty New/Used Year Make Phone #: Model
(Signature)
By: **FOR DEALER USE ONLY** Contact: Fax #: Chassis Price: Description of Body & Attachments
(Signature)
Date:
Body Price: Total Sale Price Dealer Cost
Mileage: Vin #: GVW:
FORM: 6288
Total Selling Price: Sales Tax: Net Trade Ins: Down Payment: Admin. Fee: Advance Rentals: Amt. Financed/Capcost:
Finance/Lease Pmt: Term: Residual/Balloon: Add/Replace Truck: