Koch Nationalease Credit Application

General Information

Company Name/ Individual/ Trade Name/ DBA:	Federal Tax ID #:	Sales Tax Exempt #:	USDOT #  * Fields in Red are required fields.
Street Address:	City:	State:	Zip Code:
		-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT
Billing Address:	City:	State:	Zip Code:
Same as above		-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT
Phone:	Fax:	Date Established:
Company Organization Type:	Business/Industry Type:	Accounts Payable Contact Name:	Accounts Payable Email:
Individual Corporation Partnership
Units in Fleet:
# of Tractors	# of Trucks	# of Trailers
Any Repossessions:	Any Bankruptcies Fillings:	Financial Statements Available:
Yes No	Yes No	Yes No
full name of owner(s) (or authorized officer of corportation), list home address and zip code for partnership or individual
First Name:	Last Name:	Title:	Social Security #:
City:	State:	Zip:
Same as above	-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT
First Name:	Last Name:	Title:	Social Security #:
City:	State:	Zip:
	-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT

Insurance Information

Insurance Company:	Phone #:	Policy #:
City:	State:	Zip:
	-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT

Employment

Employer Name (complete):	Phone #:	Contact:
City:	State:	Zip:
	-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT

Credit References

Complete Name:	Contact Person:	Account #:	City:	State:	Phone #:
				-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT
Complete Name:	Contact Person:	Account #:	City:	State:	Phone #:
				-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT
Complete Name:	Contact Person:	Account #:	City:	State:	Phone #:
				-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT
Complete Name:	Contact Person:	Account #:	City:	State:	Phone #:
				-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT
Complete Name:	Contact Person:	Account #:	City:	State:	Phone #:
				-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT

Bank References

Name of Bank:	Loan Officer:	Checking Account #:	City:	State:	Phone #:
				-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT
Name of Bank:	Loan Officer:	Checking Account #:	City:	State:	Phone #:
				-- Select State -- AB AG AI AK AL AN AP AR AV AY AZ BA BC BE BG BJ BU BY C CA CE CI CO CQ CT CU D DC DE DR E EE EL EN ER ES FA FL FY G GA GH GJ GT GU H HI HL IA IC ID IE IL IN IR IS IT JH JS JU KD KS KY L LA LE LL MA MB MD ME MH MI MK MN MO MS MT MX MY N NB NC ND NE NF NG NH NI NJ NL NM NO NS NT NV NX NY O OH OK ON OO OR OV OW PA PE PO PQ PR QA QC R RA RC RD RF RG RI S SA SC SD SE SG SH SK SL ST T TA TC TH TK TM TN TS TT TW TX UL UT VA VI VT W WA WI WV WY Y YT

FCRA Consumer Rights
Collection Notice

Check This Box: By checking this box, I am providing written instructions to Koch Nationalease (KNL) under the federal Fair Credit Reporting Act and applicable state law, authorizing KNL to obtain information about me today from consumer reporting agencies, and Demand Deposit Account data, such as checking account information, to determine if I am eligible for the extension of credit or sponsorship of a guarantee today and in the future. I am authorizing KNL to use consumer report information that it collects for analysis and to otherwise improve the products and services it offers, or for other similar purposes. KNL will not share your information with any third-parties. This authorization is valid for the purposes of verifying information given pursuant to the lawful purpose of business negotiations covered under the FCRA. Upon request, KNL will provide me with the name and address of the Consumer Reporting Agency used to furnish the report. I understand that credit inquiries have the potential to impact my credit score.