Application for Credit
NAME/TRADE NAME: ____________________________________________________________________________
STREET / SHIPPING ADDRESS: ____________________________________________________________________
CITY / STATE / ZIP: ___________________________________________________COUNTY: ________________
PHONE NUMBERS: (OFFICE) (FAX)
(CELL) (E-MAIL)
MAILING ADDRESS (IF DIFFERENT): _______________________________________________________________
Social Security #:____________________ Federal ID #:_______________ Ind. ____ Part. ____ Corp. ____
List below the following: Corporate Officers, Individual Owner* or Partners*
Name Title Home Address Home Phone Social Security / Date of Birth
1.________________________________________________________________________________________________
2.________________________________________________________________________________________________
3.________________________________________________________________________________________________
(*) Necessary if Individual, Owner or Partners
Financial Information
No.Trucks Owned & Operated: Mack ____, Volvo_____ Other ____ Sales Tax Exempt: Y__ N__ (Attach Exemption certificate)
Purchase Order required: Y_____ N_____ No. Invoices Required: Y_____ N_____ Credit Limit Requested:
Type of Business: _______________________________ Years in business ___________
Trade References
Name Address/City/State Fax Number Type Account/Account Number
1.________________________________________________________________________________________________
2.________________________________________________________________________________________________
3.________________________________________________________________________________________________
Banks & Finance Companies
Name Address/City/State Phone Number Type Account/Account Number
1.________________________________________________________________________________________________
2.________________________________________________________________________________________________
3.________________________________________________________________________________________________
By signing this application, The Officer or Signor of the above Individual or Business grants Nextran Rental & Leasing permission to contact the
listed references and Applicant's creditors to obtain credit information. NEXTRAN CORP, its agents and assignees may receive from and
disclose to other persons, including reporting agencies, information about my accounts and credit experiences and I hereby authorize any person
to release to NEXTRAN CORP, its agents and assignees my credit experience and account information. This shall be a continuing authorization
for all present and future disclosures of account information and credit experience made by NEXTRAN CORP, its agents and assignees or any
other person requested to release such information to NEXTRAN CORP, its agents and assignees.
If this Application is approved, Applicant agrees to pay all purchases within thirty days from the invoice date. Accounts not paid within our net
thirty- day terms may be placed on COD status. In addition, any such accounts shall bear interest at 1.5% simple interest per month (18% simple
interest per annum) from the Due Date. In the event that collection procedures are required to collect a delinquent account, Nextran Rental &
Leasing will be entitled to recover all costs of collection, included but not limited to reasonable attorneys' fees, court costs and interest. This
Application and any agreements contemplated to be executed with it shall be governed under the laws of the State of Florida.
Print Signature Name: ___________________________________________________
Signature: _____________________________________________________________
Title or Position: ________________________________________________________ Date: ____________________
