. DaimlerChrysler Financial Services Americas LLC Individual Purchaser/Lessee Statement ***TFFF1330 (05/13/03) F&I Pro (PSIN - 1.6) DCS-571A (12/20/02) 2/28/2007 Page 1 of 2 Type of Application: Business Individual New Used Salesperson 9s Name: ____________________________ Dealer Name: Dealer Phone: Dealer Fax: INDIVIDUAL/PARTNERSHIP INFORMATION: 1 st Time Buyer Ownership Exp. Number of trucks you currently: Operate: Own: Full Name: Social Security Number: Date of Birth: Home Phone Number Pager Number Cell Phone Number E-Mail Address Present Physical/Mailing Address: City: County: State: Zip: How Long at Present Address?
Years: Months: Rent Own Live with relatives Monthly Payment: Previous Address (If less than 2 years) Co-Buyer Co-Buyer 9s SSN: Co-Buyer 9s Phone Number: Present Physical Address: City: County: State: Zip: Employer Time on job Income NEAREST RELATIVES/PERSONAL REFERENCES NOT LIVING WITH YOU: Name Address City State Zip Phone Name Address City State Zip Phone CORPORATION/LEGAL ENTITY INFORMATION (If Applicable) Exact Legal Name of Corporation/Legal Entity: Inc. LLC Other Federal ID# Year of Organization Principal Officer Social Security Number Title % Owned US DOT Number MC Number CURRENT EMPLOYMENT INFORMATION Total Years of Driving Experience Years as Owner Operator Years as Company Driver Name: City: State: Phone: Contact Years at Current Employer Months Income Other Annual ... more. less.
Income Company Driver Owner Operator Other Source Amount FUTURE EMPLOYMENT Name City/State Phone Number Contact Monthly Miles Monthly Revenue Paid /mile % of Gross Products to be Hauled Commercial DL# State PREVIOUS EMPLOYERS Name City State Phone Number Contact How Long? Name City State Phone Number Contact How Long?<br><br> Name City State Phone Number Contact How Long? Trucks/Trailers Owned Description of Collateral Lending Institution City/State Phone # Account # . DaimlerChrysler Financial Services Americas LLC Individual Purchaser/Lessee Statement ***TFFF1330 (05/13/03) F&I Pro (PSIN - 1.6) DCS-571A (12/20/02) 2/28/2007 Page 2 of 2 Real Estate Lending Institution City/State Phone # Account # Autos Owned Lending Institution City/State Phone # Account # Bank Account Type Institution City/State Phone # Account # AUTHORIZATION TO RELEASE CREDIT INFORMATION The undersigned ( cApplicant d) certifies that: (a) all of the information contained herein or provided in connection with this A pplication is true and correct and accurately describes the financial condition of Applicant as of the date hereof; and (b) I will notify DaimlerChrysler Financial Services Americas LLC, its successors and assigns ("DC Financial Services") if I become aware of any material change in the financial condition of Applicant.<br><br> I hereby authorize DC Fi nancial Services and/or Dealer to make inquiry into, to request, and to receive any information concerning my financial condition, including, but not limited to, obta ining a credit report and contacting any current or former creditors of Applicant to verify any information contained herein or received in connection with this Application, wh ich DC Financial Services and/or Dealer deems relevant to the possible extension of credit to Applicant. I also grant any such creditors permission to release informat ion relating to my financial condition or my loans or leases to DC Financial Services and/or Dealer or any of their affiliates. I authorize DC Financial Services to file a UCC financing statement.<br><br> I have applied for a loan or extension of credit from DC Financial Services and I intend to use the purchased Equipment primarily for business or co mmercial purposes, and not for personal, family, household or agricultural purposes. The foregoing provision shall remain in effect until Applicant pays DC Financial S ervices in full (if DC Financial Services decides to grant credit to Applicant. Applicant Signature: _______________________________ Title (if applicable): ___________________________________ Date: ______________________ Co-Applicant: __________________________ Title (if applicable): ___________________________________ Date: ______________________<br><br>