Applicant Form – Pro-Lease Trucking

Applicant Information

Carrier Contracting With

Recruiter Name

Who referred you to us?

First Name

Middle Name

Last Name

Social Security Number

EIN#

Phone Number

Birthday

Marital Status

Spouse’s Name

Spouse’ Birthdate

Current Address

Address

Address 2

City

State

ZIP

How long at current address

E-Mail

Previous Address

Address

Address 2

City

ZIP

State

Previous Address

Address

Address 2

City

State

ZIP

Emergency Contact

First Name

Last Name

Relationship

Phone Number

Financial Disclosure

Have you ever declared bankruptcy?

Yes No

Do you owe past due child support?

Yes No

Have you ever had a repossession?

Yes No

Have you ever had a tractor abandonment?

Yes No

Driver's License Information

Driver’s License Number

State

Expiration Date

Employment History

Are you a first-time owner operator?

Yes No

If No: time as owner operator

Your business name or DBA

Current Employer

Phone Number

How Long

Types of Hauls

Previous Employer

Phone Number

How Long

Types of Hauls

Previous Employer

Phone Number

How Long

Types of Hauls

Previous Employer

Phone Number

How Long

Types of Hauls

Previous Employer

Phone Number

How Long

Types of Hauls

Co-Applicant Information (if applicable)

First Name

Middle Name

Last Name

Social Security Number

Birthdate

Marital Status

Spouse’s Name

Spouse’s Birthdate

Co-Applicant Current Address

Current Address

Current Address 2

City

State

ZIP

How long at current address

E-Mail Address

Co-Applicant Previous Addresses

Previous Address

Previous Address 2

City

State

ZIP

Co-Applicant Emergency Contact

Emergency Contact

Phone Number

Relationship

Co-Applicant Financial Disclosure

Have you ever declared bankruptcy?

Yes No

Do you owe past due child support?

Yes No

Have you ever had a repossession?

Yes No

Co-Applicant Driver License Information

Driver's License Number

State

Expiration Date

Agreement and Signature

Agreement

I hereby certify that the information contained in this application is true and accurate. I agree that B&G Leasing LLC may obtain, use and rely on for any permissible purpose information compiled by third party vendors for commercial use and sale, including without limitation that regarding the Applicant's and any Co-Applicant's financial condition, payment history, employment, assets, and personal history. By signing below or submitting electronically, I, the undersigned individual, who is either a principal credit applicant or a guarantor of its obligations, provides this written instruction to B&G Leasing LLC, its nominees or assigns, authorizing review of his/her personal credit and financial information on all business principles requested as part of said investigation. Such authorization shall extend to obtaining a credit profile in consideration of this application and subsequently for the purpose of update, renewal or the extension of such credit or additional credit and for reviewing and collecting the resulting account. I hereby authorize our banks, trade references, and financial institutions to release credit information to B&G Leasing LLC and/or affiliates or assigns. A photostat or facsimile copy of this authorization shall be valid as the original. We affirm our identity as the respective individuals in the related application. All duplicates are to be viewed as valid as the original.

Applicant Signature

Applicant Signature Date

Co-Applicant Signature

Co-Applicant Signature Date

Pro-Lease Trucking Application

Applicant Information

Current Address

Previous Address

Previous Address

Emergency Contact

Financial Disclosure

Driver's License Information

Employment History

Co-Applicant Information (if applicable)

Co-Applicant Current Address

Co-Applicant Previous Addresses

Co-Applicant Emergency Contact

Co-Applicant Financial Disclosure

Co-Applicant Driver License Information

Agreement and Signature

Thank you for your interest in Pro-Lease Trucking.

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