CREDIT APPLICATION - Truck Country

CREDIT APPLICATION

3201 Hwy 61/151 ? Dubuque, IA 52003 800-553-3642 ? Fax 563-556-3420

Please complete and fax to 563-556-3420 or e-mail to dansargent@

Interested in: New Used Not Sure Salesperson you are working with___________________________ Purchaser Present Information Full Name_________________________________________________________________________ D.O.B. ___________________ Drivers Lic. Number____________________________________________ State ______________ Exp. Date _______________ Address ____________________________________________________________________________________________________ City __________________________________________________________ State ______________ Zip _____________________ Soc. Sec. # _________________________ Contact Phone _________________ E-Mail _________________________________ At Current Address for _____Yr _____Mo Rent Own Spouse Name _________________________________________D.O.B._____________ Soc. Sec. # _______________________

If a Corporation N/A Partnership Sole Proprietorship Corporation

Company Name _______________________________________________ Date Incorporated_______________ State ________ Principal Owner _______________________________________________ Tax ID _______________________________________ Business Address ______________________________________ City _____________________ State ________ Zip ________ Business Phone ________________________________________ Business Fax________________________________________

Trucking Experience Materials Hauled ____________________________________________________________________________________________ Radius ______________Income _____________________# of Years in Trucking _______________________________________ # of Trucks Owned________________________________# of Trailers Owned _________________________________________ # of Years as Owner/Operator ______________________

Employment (Last 5 Years) Future Employer Company _____________________________________________________ How Long?_________ Yr ______Mo Contact ______________________________________________________ Phone _______________________________________ City __________________________________________________________ State ______________ Zip _____________________ Current Employer Company _____________________________________________________ How Long?_________ Yr ______Mo Contact ______________________________________________________ Phone _______________________________________ City __________________________________________________________ State ______________ Zip _____________________ Previous Employer Company _____________________________________________________ How Long?_________ Yr ______Mo Contact ______________________________________________________ Phone _______________________________________ City __________________________________________________________ State ______________ Zip _____________________

Financial History

Any Repossessions? Yes No If Yes, When? _____________________________________________________________

Bankruptcy?

Yes No If Yes, When? _____________________________________________________________

Bank Reference and Contact Person Checking and Savings Bank: ________________________________________________________ Location:___________ Account#: ________________ Contact: __________________________________________________________________________ Phone:___________________ Loans Bank: ________________________________________________________ Location:___________ Account#: ________________ Contact: __________________________________________________________________________ Phone:___________________

PRIMARY CREDIT REFERENCES # Installment Loans: Equipment, Trucks, Autos, Business Loans - No Credit Cards This area must be completed! First Reference Name:________________________________________________________ City: _______________ State:____________________ Contact: ______________________________________________________ Phone:_____________ Account#: ________________ Second Reference Name:________________________________________________________ City: _______________ State:____________________ Contact: ______________________________________________________ Phone:_____________ Account#: ________________ Third Reference Name:________________________________________________________ City: _______________ State:____________________ Contact: ______________________________________________________ Phone:_____________ Account#: ________________

For the purposes of procuring and maintaining credit, the undersigned submits the foregoing statement and information,

We hereby grant permission to all above creditors to release our account information. This shall be a continuing authorization for all present and future disclosures to account information and credit experience

Signatures (Required) By _______________________________________________________________________________ Date_____________________ By _______________________________________________________________________________ Date_____________________ The undersigned understands that Truck Country and/or its assignees will not process a credit order until after Truck Country or such assignees have conducted a credit investigation and determined, in its or their sole discretion, to approve the extension of credit to the undersigned. By submitting this Credit Application, the undersigned hereby authorizes a full and complete investigation by Truck Country and its assignees into the undersigned's credit history. The undersigned further authorizes Truck Country and its assignees to conduct an investigation into the credit history of the undersigned's proprietors, partners, shareholders, members and/or principals as Truck Country and/or its assignees see fit in its or their sole discretion. The undersigned hereby grants permission to all of the above credit references and further authorizes the use of this document (or a facsimile thereof) as consent for the release to Truck Country and its assignees of credit information by credit reporting agencies, credit bureaus, and the credit, banking and trade references supplied to Truck Country and its assignees by the undersigned. Truck Country and its assignee shall be further authorized to conduct periodic credit checks and reviews of the credit history of the undersigned and its proprietors, partners, shareholders, members and/or principals in order to continue the extension of credit to the undersigned.

Please complete and fax to 563-556-3420 or e-mail to dansargent@

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