Hill Individual Purchase Statement

Please fill in all the blanks to enable us to more effectively respond to all of your answers. When you are finished, click the Submit button to send the information to us. Note: The fields marked with and asterisk (*) are required. If a question below does not apply to you please type NA in the space provided.

NOTE: You should also e-mail or fax any additional year-end financial statements for the past two years and current prior month-end financial statements. Financial statements should include balance sheet, profit and loss statement, and statement of cash flows. E-mail them to info@hillfreightliner.com or fax to (574) 262-3443.

Customer Information:
*Purchaser:
*Address:
*City:
*State: *ZIP:
*E-mail:
*ICC #:
*SS #:
*Fed. ID #:
*Date Of Birth:
*Years At present Address:

Previous Address:
*A minimum of one row must be completed for the form to submit.
Street: City: State: ZIP: Since:

*Home Of Principal:
 Own/Buying Renting Mobile Home Live w/ Relatives

Spouse Information:
Name       Date Of Birth  
SS #          Employer       
Time On Job           Annual Income

Employment Information:
*Truck(s) to be operated for *Contact
*Phone *Employed (how long?)
*Employment Type Of Contract Written Oral
*Years In Trucking (applicant)
*Commercial Drivers License # *Expires

Previous Employment:
*A minimum of one row must be completed for the form to submit.
Company: Phone: Employed:
(years) 		Occupation:

Bank References:
*A minimum of one row must be completed for the form to submit.
Name: Contact: Phone: City: State. Acct. No.

Equipment Financing & Leasing References:
(This information should correspond with thee information contained in the attached financial statements. Include paid out creditors if this information is available.)
Name: Contact: Phone: City: State: Acct. #:

Legal Actions:
*Prior Bankruptcy: Yes No     *Tax Liens:     Yes No
*Lawsuits Pending: Yes No    *Judgments: Yes No

Insurance:
Would you like a QUOTE on Physical Damage Insurance? We can sell insurance either in your finance contract or on a direct billing basis for this unit or for your entire fleet.
Yes No

Credit Life Insurance (FINANCE DEALS ONLY) is not a factor in the approval of credit, is not required by the seller, and is for the term of credit only. Do you want Credit Life Insurance?
Yes No


Signature:
For the purposes of procuring and maintaining credit, the undersigned submits the foregoing statement and information, including any supplemental sheets, as being a full, true, and correct statement of my/our financial condition on the date stated.

Please e-mail or fax any additional year-end financial statements for the past two years and current prior month-end financial statements. Financial statements should include balance sheet, profit and loss statement, and statement of cash flows. E-mail them to info@hillfreightliner.com or fax to (574) 262-3443.

By electronically signing your name (typing) you are agreeing to let Hill Truck sales utilize all necessary tools to check your credit standing. This includes doing a credit check and report.

*Signature:
*Date: