THIS FORM CAN BE SUBMITTED ON LINE, PRINTED AND MAILED OR
FAXED TO:
HOLBERT TRAILER
SALES AND SERVICE
6001 BROOKSHIRE
BLVD.
P.O.
BOX 669243
CHARLOTTE, NC
28266
PHONE
(704) 394-2154 * FAX (704) 394-2159
PURCHASER
STATEMENT
DATE:
DEALER NAME PHONE #
CALLED IN BY: TIME CALLED
IN: INQUIRY:
NAME: SOCIAL SECURITY
NUMBER:
ADDRESS:
CITY: STATE:
ZIP CODE:
PHONE # DATE OF
BIRTH:
HOW LONG (YEARS): OWN
RENT MORTGAGE BALANCE
ORIGINAL BALANCE
FORMER ADDRESS (5 YRS. MINIMUM)
CITY STATE
ZIP CODE HOW LONG
SPOUSES NAME (FIRST, M.I.,LAST)
DATE OF BIRTH SOCIAL
SECURITY NUMBER
SPOUSES EMPLOYER PHONE
NUMBER
POSITION HELD HOW LONG
(YEARS)
BUSINESS NAME OR NAME TO APPEAR ON TITLE
DATE INCORPORATED
BUSINESS TAX I.D.#
BUSINESS NAME (IF DIFFERENT THAN ABOVE)
BUSINESS PHONE NUMBER
NAME AND ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU:
RELATIONSHIP
SPOUSE:
HAVE YOU EVER TAKEN BANKRUPTCY? YES
NO
EXPLAIN:
ARE YOU A DEFENDANT IN ANY LEGAL ACTION? YES
NO EXPLAIN:
HAVE YOU EVER HAD ANY ITEM REPOSSESSED? YES
NO EXPLAIN:
TRUCK USAGE
HOW LONG AS OWNER/OPERATOR?
YEARS OF EXPERIENCE: NUMBER OF
POWER UNITS
NUMBER OF TRAILERS
TRUCK TO WORK FOR- COMPANY NAME:
ADDRESS:
CITY STATE
ZIP CODE
CONTACT:
PHONE NUMBER
TRUCK BETWEEN WHAT POINTS
PRODUCT HAULED
OFF HIGHWAY USE? YES
NO AVERAGE MILES PER
MONTH
PURCHASER TO DRIVE: YES
NO
IF NO PROVIDE INFORMATION ON PERSON WHO WILL DRIVE
TRUCK:
DRIVER NAME (FIRST,M.I., LAST)
ADDRESS: CITY
STATE ZIP CODE
OPERATOR LICENSE NUMBER
STATE DATE
SOCIAL SECURITY NUMBER
RELATIONSHIP
EMPLOYMENT HISTORY FOR
PAST 5 YEARS (PRESENT OR LAST EMPLOYER FIRST)
(1) NAME OF COMPANY
PHONE NUMBER
ADDRESS
CITY STATE
ZIP CODE
POSITION
HOW LONG
(2) NAME OF COMPANY
PHONE NUMBER
ADDRESS
CITY STATE
ZIP CODE
POSITION
HOW LONG
(3) NAME OF COMPANY
PHONE NUMBER
ADDRESS
CITY STATE
ZIP CODE
POSITION
HOW LONG
ASSETS (WHAT YOU OWN)
LIABILITIES (WHAT YOU OWE)
CASH ON HAND MONEY
IN BANKS
LOANS ON VEHICLES:
(1) COMPANY
CITY STATE
PHONE #
ACCOUNT NUMBER
(2) COMPANY
CITY STATE
PHONE #
ACCOUNT NUMBER
REAL ESTATE:
OWN RENT
MONTHLY PAYMENTS
MORTGAGE ON REAL ESTATE:
COMPANY CITY
STATE PHONE #
ACCOUNT #
OTHER ASSETS (ITEMIZE):
OTHER DEBITS (ITEMIZE):
TOTAL LIABILITIES:
NET WORTH TOTAL ASSETS
TOTAL LIABILITIES & NET WORTH
INCOME STATEMENT
TIME PERIOD: FROM
TO
GROSS TRUCKING INCOME
OTHER INCOME
DEDUCTIONS & EXPENSES:
OPERATING PROFIT:
CREDIT REFERENCES( LIST
CREDIT REFERENCES ON PAID ACCOUNTS)
(1) NAME:
CITY: STATE
PHONE #
CONTACT PERSON:
ACCOUNT # HIGHEST OWING:
(2) NAME:
CITY: STATE
PHONE #
CONTACT PERSON:
ACCOUNT # HIGHEST OWING:
(3) NAME:
CITY: STATE
PHONE #
CONTACT PERSON:
ACCOUNT # HIGHEST OWING:
(4) NAME:
CITY: STATE
PHONE #
CONTACT PERSON:
ACCOUNT # HIGHEST OWING:
(5) NAME:
CITY: STATE
PHONE #
CONTACT PERSON:
ACCOUNT # HIGHEST OWING:
BANK REFERENCE NAME:
CITY STATE
PHONE #
ACCOUNT # OR CONTACT PERSON
THE FOREGOING
APPLICATION HAS BEEN READ (BOTH PRINTED AND WRITTEN MATTERS) AS IS IN ALL
RESPECTS
COMPLETE ACCURATE
AND TRUTHFUL THE UNDERSIGNED HEREBY AUTHORIZES THE ABOVE NAMED BANK(S).
TRADE AND/OR
OTHER CREDIT REFERENCE(S) SUCH INFORMATION AS IS NECESSARY TO ESTABLISH CREDIT
WITH
YOUR
COMPANY.
DATE:
NAME:
DEALER OR SALESMAN (SIGNATURE)
CUSTOMER SIGNATURE, TITLE:
EQUIPMENT PURCHASED
SELLING PRICE:
COLLATERAL:
TRADE IN ALLOWANCE:
NEW USED
YEAR MAKE
MODEL
ENGINE AMOUNT OWING
TRANSMISSION
SUSPENSION WHEELBASE
NET ALLOWANCE
SLEEPER OTHER
CASH
TOTAL DOWN AFV:
APPROVAL
AMOUNT TO FINANCE:
PERCENT DOWN %
ADVANCE%
RATE RATE
TERM MCS:
TRADE IN: YEAR
MAKE MODEL
VALUE OF TRADE
FORM COMPLETED BY:
CALL BACK TO: DATE
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