Untitled Document

Arthur Glick Trucks -

FINANCIAL CREDIT APPLICATION (PLEASE PRINT OR TYPE)

PERSONAL INFORMATION

NAME:	First					Middle Initial	Last	Date of Application

Social Security Number	Date of Birth	No. of dependents

Marital Status
Married
Widowed
Single
Separated
Divorced

Address

Phone Number

City, State, Zip Code

How long at this address

How long in area

Yrs

Former addresses (Five year minimum)

City, State, Zip Code

How long?

Yrs

Business name	Business Tax I.D. Number

Business Address (If different from above)	Business phone Number

EMPLOYMENT HISTORY FOR PAST FIVE YEARS (PRESENT OR LAST EMPLOYER FIRST)

1) Name and address of company	Phone no.	Position (s) Held	How long?

2) Name and address of company	Phone no.	Position (s) Held	How long?

3) Name and address of company	Phone no.	Position (s) Held	How long?

COMPLETE THIS SECTION ONLY IF THIS IS A JOINT APPLICATION WITH YOUR SPOUSE, OR IF YOU ARE RELYING ON YOUR SPOUSE'S INCOME OR ASSETS AS A BASIS FOR REPAYMENT OF THE CREDIT REQUESTED, OR IF YOU RESIDE IN COMMUNITY PROPERTY STATE

Spouse's name (First, M.I, Last)	Social security Number	Date of birth

Spouse's Employer	Position (s) Held	How long

Nearest relatives not living with you	Address	Relationship

SPOUSE

Have you ever taken bankruptcy?

Are you a defendant in any legal action?

Have you ever had any item repossessed

Yes - Explain Below

Explanation :

TRUCK USAGE

How long as owner/operator?

Operator license number

State

Date

Purchaser to drive?

If no, provide information below on person who will drive truck.

Yrs

Yes
No

Driver's name (First, M.I. Last)

Address

Years of Experience

Operator license number

State

Date

Social security No.

Yrs

Truck to work for - company name

Address

If trucking-between what points	Off-Highway use		Average mileage per month
	Yes	No

FIRE, THEFT, CAR, AND COLLISION INSURANCE IS REQUIRED

Name of agent

Address

Phone no

Name of company

Address

Coverage to be subject to mileage restriction?

Yes

BALANCE SHEET (Attach additional sheets if necessary)

ASSETS (What you own)

LIABILITIES (What you owe)

Cash on hand & in banks

Accounts receivable

Accounts Payable

Vehicles Owned

Loans on Vehicles

Company	City/State	Phone no	Account no

Real Estate

Monthly Real Estate Payment

Mortgages on Real Estate

Own
Rent

Company	City/State	Phone no.	Account no

Other Assets (Itemize)

Other Debts (Itemize)

Total Assets

Total Liabilities

Net Worth

Total Liabilities & Net Worth

INCOME STATEMENT

Time period-from-to		Gross trucking income	Other income	Deductions & expenses	Operating profit

CREDIT REFERENCE (List credit references on paid Accounts)

Name

City

State

Phone no

Contact/person

Account no

Highest Owing

Bank reference name

City/State

Account no.

For the purpose of establishing and maintaining credit, the undersigned submits the foregoing statement and information contained on this sheets, if any as being a full, true, and correct statement of my financial condition and all above matters, on the date stated. the undersigned aggress to notify you immediately in writing of any materially unfavorable change in my financial condition or the above matters, and in absence of such notice or of a new and full written statement here in may be general reputation, personal characteristics, mode of living, and all information from creditors which PFC drems relevant for the granting and collection of the purpose borrowing, if any is granted. upon my written request, additional information as to the scope of this inquiry, if one is made. will be provided.

I further represent that neither the undersigned, any principal officer of the undersigned, nor any contetemplated operator or any equipment proposed to be purchased has any record or reputation of having violated any federal or state laws relating to liquor, narcotics or contraband : and no such person has been convicted of any felony.

I understand that PACCAR Finanancial Corp. and or seller of motor vehicle, parts or services to when this application is presented, will be relying on the accuracy of the matters set forth herein as a basic of extending any credit which I may receive.

Signature

Date

Signature

Date