Individual Purchaser/lessee Statement

SELLER-PURCHASER
Seller: AGAR TRUCK SALES, INC.
Address: 2 AGAR STREET
CITY: YONKERS STATE: NY ZIP: 10701

Purchaser:

Address:

City: State: Zip:

Phone:

CUSTOMER INFORMATION

Individual  Partnership

DOB:

Social Security #

Years at Present Address:

Previous Address:

Street:   Since:

City: State:   Zip:

Street: Since:

City:  State:   Zip:

 

Home of Principal:

Own/Buying    Renting    Mobile Home    Live with Relatives

Spouse Information:

DOB:   Social Security NO:

Employer:   Phone:

Time on Job:  Years Months Annual Income

 

Employment Information:

Truck(s) to be operated for:     
Contact:   Phone: 

Employed:  Years Months 

Type of Contract:  Written  Oral

Total Years in Trucking No of Trucks Owned No of Trucks Leased

Type of Use:

Commercial Drivers License # : Expires:

 

Previous Employment:

Company:

Contact:    Phone:

Employed:  Years   Months Occupation:

Company:
Contact:    Phone:
Employed:  Years   Months Occupation:
Financial Information:
References (Relatives or Friends not living with you)
Name: City/State: Phone: Relationship:
Bank/Mortgage Company References:
Bank Name: Contact: Phone: City/State: Account No:
Equipment Financing and Leasing References*:
Bank/Finance Co: Contact: Phone: City/State: Account No:
*Include paid out creditors if this information is available.
Legal Actions:
Prior Bankruptcy: Yes   No judgments: Yes  No
Tax Liens: Yes   No Lawsuits Pending: Yes  No

Other Comments (include coverage requested)