Finance Application

Individual or Firm Name:

Street Address:

E-Mail Contact:

Type of Business:

Ownership:
	Sole Proprietor
	Partnership
	Corporation
	LLC

Principal or Officer:

Percent of Ownership:

Title:

Street Address:

Principal or Officer:

S.S. Number:

Percent of Ownership:

Title:

Street Address:

Principal or Officer:

S.S. Number:

Percent of Ownership:

Title:

Street Address:

Bank Name:

Account Number:

Phone Number:

Bank Officer:

Trade Reference:

Street Address:

Telephone:

Trade Reference:

Street Address:

Telephone:

Supplier:

Type of Equipment:

Total Cost:

Sales Person: ------------- Select ------------- None Rod Basconcillo Colin Bauer Larry Bauer Michael Lobb Rick Monroe Brian Schwindt Carolyn Schwindt Randy Watson

Additional Information:

By sending this application, the principle of and/or guarantor for the applicant provides consent to Bart Larsen Trucking and/or assigns or potential assigns, authorizing review of his/her personal credit profile from a national credit bureau, and review of bank account and trade information now and from time to time, as may be needed in the credit avaluation and review process and waves any right or claim they would otherwise have under Fair Credit Reporting Act in the absence of this continuing consent. A fax or photocopy of this authorization shall be valid as the original.

I agree.