INDIVIDUAL Credit Application - PRINT now by clicking "file" then "print" in your web browser option
Fax To: 816-861-0061 - Attn: Shawn Baker       Call 866-674-5354 for help

First Name _________________Middle Name_________________ Last Name_________________

Suffix (JR.)____

Social Security # _____________________________Date of Birth_________________

Current Address (Number & Street) ________________________________________City_________________State_______

Zip Code_________________ County____________________   Time at this address?   

Years _____ Months _____

Home Phone (       ) ______________   Cell Phone (       ) ______________email address________________________

Previous Address (If less than 3 years at current address) ______________________________________________

City_________________State_________________ Zip Code______________Time at address?

Years _____ Months _____

Spouse First Name _________________Middle ______________

Last Name__________________ spouse cosign?  Yes   No

Spouse Social Security # ________________________Spouse Occupation & Salary_____________________________

Nearest relative not living with you _______________________________Relationship_______________________

Address ________________________________________________________

Phone Number (         ) _________________   

Additional personal reference _______________________________Relationship_______________________

Address ________________________________________________________

Phone Number (         ) _________________   

Employment (past 3 years) Attach additional sheet if needed

Current Employer________________________ Phone(         ) ____________ How Long?_____________

(circle one) Company Driver      Owner Operator      Hauling What: __________________________________

Previous Employer________________________ Phone(         ) ____________ How Long?_____________

(circle one) Company Driver      Owner Operator      Hauling What: __________________________________

Previous Employer________________________ Phone(         ) ____________ How Long?_____________

(circle one) Company Driver      Owner Operator      Hauling What: __________________________________

Total Driving Experience _________ Years as Company Driver      _________ Years as Owner Operator

Carrier new truck will haul for: ____________________Phone(         ) _______________ MC# __________________

Carrier Address__________________________________________________________________________________

How will equipment will be used (circle all that apply) -  Team   Solo    miles per year _____________
48 states     Regional      Local     Dry Van     Reefer      Flat Bed      Bulk     Construction    
Driver Name if other than owner ________________________________

Phone(         ) _______________
 

Ever filed bankruptcy? (circle one)   No   Yes (explain, give discharge date)____________________________________________
Are you a defendant in any legal action? (circle one)   No   Yes   explain _____________________________________________
Have you ever had an item repossessed? (circle one)   No   Yes   explain ____________________________________________

List vehicles you own below:   CASH ON HAND & IN BANK $ ____________________________

Year/Make/Model ____________________________________Financed?   No   Yes   By whom?___________ Value $________

Year/Make/Model ____________________________________Financed?   No   Yes   By whom?___________ Value $________

Year/Make/Model ____________________________________Financed?   No   Yes   By whom?___________ Value $________

Over the Road Truck Year/Make/Model ____________________________________

Value $_____________Financed?  No  Yes 

By whom?____________________Address_____________________________

Phone(       ) ____________ Acct # _____________

Real Estate (circle all that apply)  Own  Rent   Live w/Relative    House    Land & Mobile Home  

  Mobile Home    Apartment

Mortgage Company__________________Address____________________________

Phone(       ) ___________ Acct # __________

Estimated Real-Estate Value $______________  Estimated Equity $______________  

 Monthly Payment $______________

Other Assets ______________________________________________________________

Estimated Value$______________

Other Assets ______________________________________________________________

Estimated Value$______________

List Debts except mortgage: Type____________________  Balance $______________   

Monthly Payment $______________

Type____________Balance $_______Monthly Pymt $_______      Type____________Balance $_______Monthly Pymt $_____

Type____________Balance $_______Monthly Pymt $_______      Type____________Balance $_______Monthly Pymt $_____

Type____________Balance $_______Monthly Pymt $_______      Type___________Balance

$_______Monthly Pymt $_____

Is Unit a Replacement Unit? (circle one)   Yes  No     If Yes, are you using a trade?"  Yes   No

Is Unit an Additional Unit? (circle one)   Yes  No    If Yes, # of tractors ________ trailers ________

you own  /  lease

How much will you put down? $_________________________

Source of down payment or deposit? (circle all that apply)  Trade In    Cash    Other, explain ___________________________

I certify that the information stated in this application is true and correct to the best of my knowledge.

I further certify that the vehicles leased/financed from you will be used exclusively for business

or commercial purposes. I understand that you will retain this application whether or not it is approved.

You are authorized to verify my employment history, check my credit with credit reporting agencies and

 other sources and to answer questions about your credit experience with me.

Applicant's signature ________________________________________________Date__________________________________

Spouse's signature (if requesting joint credit)__________________________________________

Date ______________________

INDIVIDUAL Credit Application - SelecTrucks of Kansas City

Fax To: 816-861-0061 - Attn: Shawn Baker   or    Call 866-674-5354 for help