CUSTOMER CREDIT PROFILE
CUSTOMER INFORMATION:
___________________________ ___________________________ _______________________
Legal or Company Name Physical Address City/State/Zip
________________________ ________________________ ______________
Contact
Person Billing
Address City/State/Zip
________________________ ________________________ __________________
Phone Number Fax Number E-Mail Address
___________________ ________________ ______________ ____________
ICC Number Social
Security No. % of Ownership SIC#
________________ ________________ __________________
____ ___
Headquarters Ph# Type of Business Federal ID No. Incorporated Yes No
___________________ ____
____ ___ ___
State Organized Under Tax Exempt Yes No Is a P.O. Required Yes No
BANKING
INFORMATION:
_______________________ ________________________ ____________________________
Bank Name Bank Phone # Bank Fax #
_______________________ ________________________ ____________________________
Bank Address City/State/Zip Account Number(s)
____________________________________ _________________________________________
Contact Name Comments
INSURANCE
INFORMATION:
______________________________ ________________________ ____________________
Insurance Agent Agents Phone # Agents Fax #
________________________ _______________________________ ____________________
Address City/State/Zip Contact Name
CREDIT
& FINANCE CO. REFERENCES (Truck or Trailer):
__________________________ _________________ ____________________________
Supplier/Finance Co. Name Phone # Contact Name & Acct#
__________________________ _________________ ____________________________
Supplier/Finance Co. Name Phone # Contact Name & Acct#
______________________________ _________________ ____________________________
Supplier/Finance Co. Name Phone # Contact Name & Acct#
FLEET
& FINANCIAL DATA:
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OWNED
|
LEASED
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RENTED |
NUMBER OF TRUCKS
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NUMBER OF TRAILERS
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CURRENT AGGREGATE MONTHLY LOAN/LEASE PAYMENTS |
$
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CURRENT AGGREGATE MONTHLY OPERATING LEASE PAYMENTS |
$
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TOTAL MONTHLY PAYMENTS |
$
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LOCATION OF TERMINAL (S)) |
OWNED |
LEASED |
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GEOGRAPHIC MARKETS SERVED |
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TYPES OF PRODUCTS HAULED |
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LIST TOP 3 ACCOUNTS & THE PERCENTAGE OF OVERALL REVENUE THEY PROVIDE
|
COMPANY NAME |
CONTACT |
PHONE NO. |
% OF TOTAL REV. |
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WHAT IS THE INTENDED USE OF THE EQUIPMENT? GROWTH___ REPLACEMENT__
I authorize the release of Credit, Banking & Insurance information to Reliant Leasing Systems and I acknowledge
that the credit terms of which I am requesting are due within 30 days.
Authorized Signature ______________________________ Date ____________________________