Virginia Truck Center
Application for Credit

Customer Information
Company Name
 Tax ID Number
 Type of Entity (Corp., LLC, Partnership...)
 Years in Business
 Date Inc./State
Address 1
Address 2
City
 State
 Zip
Contact Phone
 Fax Number
 Email Address
Customer Name/Guarantor
 Birth Date
 Social Security Number
Customer Name/Guarantor
 Birth Date
 Social Security Number
Address 1
Address 2
City
 State
 Zip
Contact Phone
 Fax Number
 Email Address
Do you rent/own/live with relative/other? (Yrs/Month)
 Time at current residence?

List 3 relatives or friends that do not live with you in the section below.
Name
 City
 State
 Contact Phone
 Relationship
 
Name
 City
 State
 Contact Phone
 Relationship
 
Name
 City
 State
 Contact Phone
 Relationship
First time owner/operator? If no, how long as owner/operator?
 Net Monthly Income

Include credit references from current and past installment loans in the section below.
Lessor/Creditor
 Contact Phone
 Date Opened
 Original Balance
 Current Balance
 Monthly Payment
 Equipment/Collateral
Lessor/Creditor
 Contact Phone
 Date Opened
 Original Balance
 Current Balance
 Monthly Payment
 Equipment/Collateral
Lessor/Creditor
 Contact Phone
 Date Opened
 Original Balance
 Current Balance
 Monthly Payment
 Equipment/Collateral
Bank Name
 Account Number
 Contact Phone
 Contact Name
Ever been bankrupt?   Yes/No   Year
 Ever had a repossession?   Yes/No   Year
Bank Name
 Account Number
 Contact Phone
 Contact Name
Mortgage Company Name
 Account Number
 Contact Phone
 Contact Name

Hauling References: Present and past employment for five years with the last employer listed first.
Company Name
 Position
 Contact Phone
 Contact Name
 Duration (Beg. Date - End Date)
Company Name
 Position
 Contact Phone
 Contact Name
 Duration (Beg. Date - End Date)
Company Name
 Position
 Contact Phone
 Contact Name
 Duration (Beg. Date - End Date)
Company Name
 Position
 Contact Phone
 Contact Name
 Duration (Beg. Date - End Date)
Company Name
 Position
 Contact Phone
 Contact Name
 Duration (Beg. Date - End Date)
Company Name
 Position
 Contact Phone
 Contact Name
 Duration (Beg. Date - End Date)

The information given on this application is true and complete. Virginia Truck Center, Inc. may receive from and disclose to other persons, including credit reporting agencies,  information about the Applicant's account and credit experience. The Applicant also authorizes any person to release to Virginia Truck Center, Inc. credit experience and account information on the Applicant. This shall be a continuing agreement for all present and future disclosures of account information and credit experience on the Applicant made by Virginia Truck Center, Inc. or any person requested to release such information to Virginia Truck Center, Inc.

By submitting this form, I hereby acknowledge my understanding and acceptance of the above statement.