Individual Purchaser Lessee Statement

TYPE OF APPLICATION:

Business Individual     New Used     SalesPerson's Name:

Dealer Name: Dealer Phone: Dealer Fax:

INDIVIDUAL / PARTNERSHIP INFORMATION

1st Time Buyers Ownership Number of trucks you currently : Operate: Owned:

FullName: Social Security Number: Date of Birth:

Home Phone Number: Pager Number: Cellphone Number: Email Number:

Present Physical/Mailing Address: City: Country: State: Zip:

How long at present address?: Years: Months:

Rent Own Live with relatives     Monthly Payment:

Previous Address (If less than 2 years):

Co-Buyer: Co-Buyer's SSN: Co-Buyer's Phone Number:

Present Physical Address: City: Country: State: Zip:

NEAREST RELATIVES/PERSONAL REFERENCES NOT LIVING WITH YOU

Name: Address: City: State: Zip: Phone:

Name: Address: City: State: Zip: Phone:

CORPORATION/LEGAL ENTITY INFORMATION (IF APPLICABLE)

Exact legal name of the corporation/Legal Entity:    Inc LLC Other     Federal ID#:

Year of Organization: Principal Officer: Social Security Number:

Title:     % Owned:     US DOT Number:     MC Number:

CURRENT EMPLOYMENT INFORMATION

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

Name: City: State: Phone:

Contact: Years at Current Employer: Months: Income:

Company Driver Owner Operator Other

Other Annual Income Source: Amount:

FUTURE EMPLOYMENT

Name: City/State: Phone:

Contact: Monthly Miles: Monthly Revenue:

Paid:     Mile: % of Gross:

Products to be Hauled: Commercial DL#: State:

PREVIOUS EMPLOYEES

Name:	City:	State:	Phone:	Contact:	How Long:
Name:	City:	State:	Phone:	Contact:	How Long:
Name:	City:	State:	Phone:	Contact:	How Long:

Trucks/Trailers Owned Description of Collateral	Lending Institution	City/State	Phone#	Account #
Real Estate	Lending Institution	City/State	Phone#	Account #
Autos Owned	Lending Institution	City/State	Phone#	Account #
Bank Account Type	Lending Institution	City/State	Phone#	Account #

LIKE-KIND EXCHANGE. As part of a like-kind exchange program, Assignee has engaged MBF Account Services, LLC as a qualified intermediary. The originating Dealer/Lessor is hereby notified that the Assignee has assigned to MBF Account Services, LLC its rights (but not its obligations) for the purchase of Equipment described in any leases. In event the Lessee or originating Dealer/Lessor purchases any Equipment, such purchaser is hereby notified that the Assignee has engaged MBF Account Services, LLC its rights (but not its obligations) for the sale of the Equipment described in such Leases.

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 DCFS USA LLC and Daimler Trust, and their respective successors, transferees 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, lease 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 for all outstanding indebtedness under all loans, leases or extensions of credit (if Creditor decides to grant credit to Customer(s)).
Applicant Name:
Title (if applicable):	Date:
Co-Applicant Name:
Title (if applicable):	Date:
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