Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
Pager Number
FAX
E-mail Address
Date of Birth
Social Security Number
Drivers License Number
State
Expiration Date
HazMat Endorsement
Number of years OTR:
OTR Miles:
DUI or Felony / YR of Offense:
In the past 3 years Number of
Speeding Tickets
Number of Moving Violations
Number of Accidents
Did you attend Truck Driving
School
Where and how many weeks
Other License # and State
Marital Status
Wife or Significant Others Name
Are they employed
Their Monthly Income
# of Children at Home
Monthly Child Support
TOTAL MONTHLY EXPENSES
Do you Own or Rent
Monthly Rental/Mortgage Amount
Landlord/Mortgage Co Name
Their Address
Their Phone Number
Savings Bank Name
Account Number
Phone Number
Checking Bank Name
Account Number
Phone Number
Previous Address (last 5 years)
Previous Address (last 5 years)
REFERENCE #1
Name,Phone,Relationship
REFERENCE #2
Name,Phone,Relationship
Relative NOT Living with
you,Phone,Relationship
Work History past 10 years
Dates,Employer,Phone#
Dates,Employer,Phone#
Dates,Employer,Phone#
Dates,Employer,Phone#
Dates,Employer,Phone#
Dates,Employer,Phone#
Dates,Employer,Phone#
Dates,Employer,Phone#
Dates,Employer,Phone#
Dates,Employer,Phone#
******Where did you hear about
us
Are you interested in a truck
purchase?
Describe the truck you want.
What price do you want to pay?
Do you Have a Trade?
Describe your trade
Payoff on Trade
Where trade is financed?
Do you prefer a lease
purchase?
This report is prepared under the Fair Credit Reporting Act (FCRA)
guidelines. I have the right to make a written request to
Truck Tech, Inc and the company Truck Tech,
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 Tech, Inc. has or obtains,
including my business history with Truck Tech, Inc. if
accepted, may be supplied to other companies. I also agree to
receive Truck Tech, Inc's inventory updates.