Nashville Location
Phone (800) 367-7712
319 Fesslers Lane
Nashville, TN 37210
Decatur Location
Phone (800) 433-6351
403 Beltline Rd. NW
Decatur, AL 35601
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Credit Application
Customer Data
Business Start Date:
Tax ID #:
State of Incorporation
C Corp S Corp LLC Partnership Sole Proprietorship Parent Company (If Applicable)
Customer Legal Name
DBA Name
Address
US DOT Number (If Applicable)
MC Number
City
County
State
Zip:
Tel #
Fax #
Owner/Guarantor Name DOB Title SSN % Owned Years w/ Company Years Experience
Finance / Insurance Information
Bank Name
Checking Account #
Contact Name
Tel #
Bank Name
Operating Line #
Contact Name
Tel #
Operating Line Secured By: Accounts Receivable All Assets Personal Guaranty Other
Vehicle Finance Reference Account # Contact Name Tel #
Any Units Financed With DCFSA/MBCC?
No Yes
Account #
Account Name:
Insurance Agency
Contact Name
Liablity Coverage
$
Pys Dam Ded
$
Tel #
Major Customers
Name
% Revenue
How Long?
Yrs
Mths
Contact Name
Tel #
Name
% Revenue
How Long?
Yrs
Mths
Contact Name
Tel #
Equipment Information
Current Fleet # Tractors
# Trucks
# Trailers
Total # Units To Be Purchased / Leased
Retail TRAC OBS TRAC FMV Fixed Float   # Months Balloon / Residual
%
Payment Stream
Level Skips (months)
Current Employment Information
Total Years Driving Experience
Years As Owner Operator
Years as Company Driver
Name
City
State
Phone
Contact
Years at Current Employer
Future Employment (if Different)
Name
City/State
Phone Number
Contact
Previous Employers
Name
City
State
Phone Number
Contact
How Long?
AUTHORIZATION OT RELEASE CREDIT INFORMATION
The undersigned certifies that: (a) all of the information contained herein or provided in connection with this Application is true and correct and accurately describes the financial condition of the Customers(s) 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 the Customers(s). I hereby authorize DC Financial Services and/or Dealer to make inquiry into, to request, and to receive any information concerning my financial condition, including but not limited to, obtaining a credit report and contacting any current or former creditors of Customer(s) to verify any information contained herein or received in connection with this Application, which DC Financial Services and/or Dealer deems relevant to the possible extension of credit to Customers(s). I also grant any such creditors permission to release information relating to my financial condition or my loans or leases to CD Financial Services and/or Dealer or any of their affiliates. I authorize DC Financial Services to file a UCC financing statement. 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 commercial purpose, and not for personal, family, household or agricultural purposes. The foregoing provision shall remain in effect until Customer pays DC Financial Services in full (if DC Financial Services decides to grant credit to Customers(s)).
Customer
By
Title
Date
Guarantor Name
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