Credit App Please complete this form and a representative will be in touch shortly. Step 1 of 4 25% Last Name* First Name* Middle Name SuffixSelectSrJrIIISocial Security Number* Date of Birth* MM slash DD slash YYYY Marital Status Single Married Divorced Other Phone*Cell-PhoneEmail* Address* City* State* Zip* How long at this address?* How long in the area? Former Address (Five Year Minimum) City State Zip Have you ever declared bankruptcy?* No Yes-Explain below Please ExplainAre you a defendant in any legal action?* No Yes-Explain below Please ExplainHave you ever had any item repossessed?* No Yes-Explain below Please Explain How long have you been an owner operator / fleet owner? Total experience as a professional driver? CDL Number State Date MM slash DD slash YYYY Business Name Federal Tax ID State Incorporated Date Incorporated MM slash DD slash YYYY What percentage of the company do you own? Name of additional owner? Business Address City State Zip Do you have your own authority? Yes No How long? Haul or Brokerage CompanyPhone NumberContactHow Long? How many trucks currently owned? YearMakeModel How many trailers currently owned? YearMakeModel Have you financed trucks or trailers before?Equipment LenderAddressCitySTZIPPhone If you have less than 5 years of driving experiencePrevious EmployerPhone NumberContactHow Long? Cash on hand & in Bank - BankReal Estate Own Rent Monthly payment Paid to whom? Personal AutoYearMakeModelMonthly PaymentPaid to whom? Additional AssetsHomeLandStock401K Additional DebtBalanceMonthly PaymentPaid to whom? By signing below, the undersigned individual(s) who is either a principal of the credit applicant or a personal guarantor of its obligations, provides written instruction and authority to Werner Enterprises Inc. &/or Fleet Truck Sales or its Designee as well as a and in addition to any assignee or potential assignee thereof authorizing review of his/her personal credit profile from a national credit bureau. Such authorization shall extend to obtaining a credit profile in considering this application and subsequently for the purposes of update, renewal or extension of credit or additional credit and for reviewing or collecting the resulting account. A photocopy or faxed copy of this authorization shall be valid as the original. The Federal Equal Credit prohibits creditors from discriminating against credit applications on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract), because all or a part of the applicant’s income derives from any public assistance program, or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The Federal agency that administers compliance with this law concerning this creditor is: Federal Trade Commission, Equal Credit Opportunity, Washington D.C. 20580.* I agree to Werner Fleet Sales Company Online Credit Application Agreement Signature*Date* MM slash DD slash YYYY Δ