DiamlerChrysler Truck Commercial Credit Application
Thank you for choosing to set up a credit account with Northwest Ford and Sterling Truck Centers. Simply fill out the application below to set up an account with us. Print this application out, then fill in the spaces and fax it to us.
Ray Vine our business manager will contact you after setting up your account. If you have any trouble with the application process call (847) 671-7100 ext. 253
.

Fax Number (847) 671-5827

   Seller-Purchaser:
 Seller: _______________________________________________________   Date: __________
 Address: ______________________________________________________
 City: ___________________________________________________  State: _______  Zip: ___________
 Purchaser: _____________________________________________  Phone: ( ___ ) __________________
 Address: _______________________________________________  Cell Phone: ( ___ ) _______________
 City: __________________________________________________  State: _____  Zip: ___________

   Business Information:
C Corporation
LLC
S Corporation
Partnership
Proprietor
Other: _____
 Number of Years in Business: _________
 Nature of  Business: Construction
Mixer         (Concrete)
Tank
Agricultural
Delivery
Crane
Food/
        Grocery
Hazardous
Municipal
Refuse
Tow         Recovery
Other         (specify):
Material         Hauling
Beverage

_______________
 Is Business Seasonal?
Yes   No


 Inactive Month (s) ________________
 Annual Mileage:


      ___________
 Equipment  Operates: Local
Regional
Interstate
Intrastate








   Officers/Key Managers:
 Name:  Title:  Stock Ownership %:  Yrs. w/Co:  Years Exp:
     
 
     
 

   Sources of Revenue:
 Contracts or Customers:  Years of Association:  $ Revenue/Year:  % Total Rev.:
 
 
 
 
 Other income:
 Source(s) of other income: alimony, child support or separate maintenance income need not be disclosed if you do  not wish to have it considered as a basis for repaying this obligation.
        Source(s): (WA)


        _______________________
        Additional Mo. Income


        $______________________

   Equipment Purchase Information:
New:
Used:
 Year:  Make:  Model:  VIN:  Price of Unit:

   Attachment Information:
 Year:

 Description:  Make:  Model:  Serial Number:  Price of Unit:


Selling Price:  

_____________________
 
- Gross Price:
 _____________________
Term:  _____________________
+ Payoff:
 _____________________
Balloon / Residual %:  _____________________
- Cash Down:  
 _____________________
Rate / Payment Factor:  _____________________
= Amount Financed/Leased:
 _____________________
 
 Skip Pymts (specify): Jan Feb Mar Apr May Jun Jul Aug Sep Oct
                                        Nov Dec

   Financial Information:
 Insurance:


      Physical Damage Deductible:   ________________
Liability Limits:   ________________

   Bank References:
 Bank Name:  Contact:  Phone:  City:  State:  Complete Acct. No:
           
           

   Equipment Financing and Leasing References*:
 Bank/Finance Co:  Contact:  Phone:  City:  State:  Account Numbers:
           
           
            
 Number of Trucks Owned:


 ___________________
 Leased:
 ___________________
 *  This information should correspond with the information contained in the attached financial statements. Include  paid out creditors  if available.
 Legal Actions:
 Prior Bankruptcy:
 Tax Liens:
Yes No
Yes No
 Judgments:
 Lawsuits Pending:
Yes No
Yes No

California Disclosure

Applicant, if married may apply for a separate account.

New York Disclosure
A consumer report may be requested in connection with this application for credit or any further update, renewal or extension of such credit. Upon request, you will be informed whether or not a consumer report was requested and, if a report was requested, you will be informed of the name and address of the agency that provides a report.

Ohio Disclosure

The Ohio laws against discrimination require that all creditors make credit equally available to all credit worthy customers and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio civil rights commission administers compliance with this law.


Wisconsin Marital Information Statement: (Must be filled in by Wisconsin Residents)
 Spouse's Name: (If other than
 Co-Applicant)

________________________________
 Is Co-Applicant Your Spouse?
Yes No
Are Married
 Spouse's Address

___________________

___________________
Legally Separated
Unmarried (The Term "unmarried" includes Single, Divorced or Widowed Persons)
Notice to Married Applicants: No provision of any marital property agreement, statutory individual property classification agreement  ("opt-out" agreement) under Section 766.587 of the Wisconsin Statutes, unilateral statement under section 766.59 or the Wisconsin Statues, or court order under section 766.70 of the Wisconsin Statues adversely affects the interest of the creditor unless the creditor receives a copy of the agreement, statement, or order or has actual knowledge of the adverse provision before extending or agreeing to extend the credit you are requesting. Is  there a marital property agreement, statutory individual property classification agreement, unilateral statement, or court order that you wish the creditor to consider in evaluating your credit application?
  Check Appropriate box:
 
No Yes   (If yes, provide the creditor with a copy of the agreement, statement or order.)

Notice to Non-Applicant Spouse (Married Applicants only): If the credit applied for is individual credit, or joint credit with an applicant who is not your spouse, the creditor is required by section 766.56 (3)(b) of the Wisconsin Statues to notify your spouse of the extension of credit.

Statement of Purpose: For a married applicant applying for individual credit or for joint credit with an applicant who is  not your spouse: The credit requested, if granted, will be incurred in the interest of my marriage or family.


  ______________________________________                             ______________________________________
    Signature of Wisconsin Applicant                                                                       Date

CREDIT REPORT.  The undersigned agrees to notify DaimlerChrysler Services North America LLC immediately in writing of any material unfavorable change in financial conditions. Dealer and/or DaimlerChrysler Services North America LLC (each "Creditor") may obtain my credit report in connection with this credit application, the credit transaction resulting form this application, or future extensions of credit by Creditor, for any aspect of the credit transaction, including but not limited to reviewing the account, taking  collection action, updating credit information or for any other Permissible Purpose under the Federal Fair Credit Reporting Act. CREDIT INVESTIGATION. I authorize the Creditor to start a credit investigation based on the information voluntarily provided by me which is true and correct and reflects all my debts. I addition, I authorize Creditor to obtain federal and state records of employment and income history, including State Employment Security Agency ("SESA") records. This SESA authorization is for this transaction only and  continues in effect for one (1) year unless limited by state law, in which case the authorization continues in effect for the maximum  period, not to exceed one (1) year, as allowed by law. BANKRUPTCY. A bankruptcy proceeding is not in progress nor expected. COPY  PROVIDED. Upon request. I will be provided a copy of this application. CERTIFICATION. I acknowledge and certify that I have applied for a loan or extension of credit form DCS and I intend to use the purchased Equipment primarily for business or commercial purposes, and not for personal, family, household or agricultural purpose. Everything I have stated in this application is correct to the  best of my knowledge.


 Signature:  ______________________________________


 Title:           ______________________________________                             Date:  _________________________
  
Guarantor Information:

 Name:      ___________________________________
Name:      __________________________________

 Address: ___________________________________

                                ___________________________________
Address: __________________________________

                               __________________________________

 SSN:        __________________________________
SSN:       __________________________________