INDIVIDUAL PURCHASER STATEMENT Want to download a PDF form pdf version to print and fax? Download here >
Sales Rep:
Sales Person:
Phone:
Transaction: Line of Credit (LOC):
Promo Code:
       
      INDIVIDUAL INFORMATION
Full Name:
Social Security:
Date Of Birth:
Home Phone:
Cell Phone:
Email:
Current Physical / Mailing Address ( street, city, state & zip):
How Long at this address?:
years months
Rent:
Own: Live with Relatives: Monthly Payment:
Gross Monthly Income:
Other Annual Income:
Source:
Amount:
Previous Address (if less than 2 years):
      CO-BUYER INFORMATION
Co-Buyer Name:
Co-Buyers Social Security:
Phone:
Employer:
Time at Job:
Income:
Co-buyer's Current Physical Address (please include street, city & zip):
      CORPORATION/LEGAL ENTITY INFORMATION (If Applicable)
Exact Legal Name of Corporation
/Legal Entity:

Corporation
(if yes,
what state?)
LLC:
Partnership:
Proprietorship:
Inc: Other:
Federal ID# :
Year of Organization:
Principal Officer:
Social Security:
Title:
% Owned:
US DOT #:
MC #:
Annual Revenues:
      CURRENT EMPLOYMENT INFORMATION
Total Years Driving Experience:
Years as Owner/Operator:
Years As Company Driver:
Other:
Company Name:
Employer City:
Employer State:
Employer Phone:
Contact Name:
Time at Current Employer:
years Months
Owner/Operator: Company Driver : Other:
Long Distance (over 150k miles) Replacement Equipment Average Miles / Year:            
Intermediate (50k - 150k miles) Additional Equipment for Increased Business Years In Trucking:                  
Local (50k - 150k miles) Additional Equipment for New Venture Current # of Trucks Owned :
Percentage Hauled in State Products to be Hauled: Commercial DL# : State:
      FUTURE EMPLOYMENT
Company Name:
City:
State:
Phone:
Contact Name:
Monthly Miles:
Monthly Revenue:
Paid:
/ mile % of Gross
      PREVIOUS EMPLOYERS
Company Name:
Contact Name:
City:
State:
Phone:
How Long?:
Company Name:
Contact Name:
City:
State:
Phone:
How Long?:
Company Name:
Contact Name:
City:
State:
Phone:
How Long?:
      CREDIT REFERENCES
Trucks/Trailers Owned/
Description of Collateral
PAID
Yes
OFF?
No
Lending Institution Original Balance Current Balance City & State Phone Account#
Real Estate                
Autos Owned                
Bank Account Type                
      AUTHORIZATION TO RELEASE CREDIT INFORMATION
The undersigned certifies that: (a) all of the information contained herein or provided in connection with this Application is true and correct and accurately describes the financial condition of the Customer(s) as of the date hereof; and (b) I will notify Crossroads Equipment Lease & Finance LLC, its successors and assigns ("Creditor") if I become aware of any material change in the financial condition of the Customer(s). I hereby authorize Creditor and/or Dealer to make inquiry into, to request, and to receive any information concerning my financial condition, including, but not limited to, obtaining a credit report and contacting any current or former creditors of Customer(s) to verify any information contained herein or received in connection with this Application, which Creditor and/or Dealer deems relevant to the possible extension of credit to Customer(s) (“Information”). I also grant any such creditors permission to release Information to Creditor and/or Dealer. I authorize Creditor to disclose Information to any affiliate, assigns or agent. I authorize Creditor to file a UCC financing statement. I have applied for a loan or extension of credit from Creditor and I intend to use the purchased Equipment primarily for business or commercial purposes, and not for personal, family, household or agricultural purposes. The foregoing provision shall remain in effect until Customer pays Creditor in full (if Creditor decides to grant credit to Customer(s)).
 
By checking this box and filling out your name in the signature field, I hereby acknowledge that it is in place of
your signature, and can be used as such.
 
08/22/2017
Applicant Signature Title Date
 
Co-Applicant Signature Title