Ag Transport Application

Legal Name:*

dba

Business Start Date:*

Date

Address:*

City:*

State:*

Zip:*

County:*

Phone:*

Fax

Contact/Mobile Phone:*

Email:

Website:

Type of Organization:*

CorporationPartnershipProprietorOther

State of Organization

Date of Organization

Date

Fed ID #:*

Owner*:*

Title:

% Ownership*

Address:*

City:*

State:*

Zip:*

Yrs at Address:

Owner*:

Title:

% Ownership

Address:

City:

State:

Zip:

Yrs at Address:

Primary Bank:*

Phone:*

Officer:

Haul Reference:*

Phone:*

Officer:

Loan Reference :

Phone:

Officer:

Nearest Relative:

Phone:

Relationship:

*complete this financial grid or include balance sheet/income statement

Total Assets:*

Total Liabilities:*

Income Summary

Most Recent Year:

Crops Planted

Farm Revenue $:*

Trucking Revenue $:*

# Acres Rent:

# Acres Own

Non Farm Income $:

Trucking Income $:

*additional financial information may be requested

Net Income $:

# Trucks Own*

# Trailers Own*

Dealer:*

Contact:*

Phone:

Is this a replacement unit?

YesNo

Year

NewUsed

Price:*

Make/Model:

Description:

Product(s) Hauling

Paymt. Frequency:

Term:

Advance:

Purchase Option:

10%20%$101

Sales Tax Exempt:

YesNo

If Yes, Why:

Transportation:

MC#ICC#

#:

Address where equipment will be located (if different than above):

Insurance Company:

Agent:

Phone:

Click to edit

SIGNATURE All information in this application and all attachments are correct to the best of my knowledge. I authorize Northland Capital and/or its lenders and assigns to verify employment and all financial and other information submitted with this application, including obtaining a consumer credit report, to act on this application. I authorize making continued inquiries about such information and obtaining a consumer credit report during the term of obligations. As required by law, my identity will be verified. I authorize all past or present creditors to release any and all necessary credit information, and to respond fully to requests for information based on this application when transmitted by electronic or other means. The above permissions and authorizations will apply to any creditor to whom this application is submitted. I certify that the obligations applied to hereunder are for business, commercial or agricultural purposes and not for personal, family and household purpose. I certify that authorization has been obtained from those listed above, however have not signed below, to obtain their consumer credit report as they are applying to Northland Capital for credit. FAIR CREDIT OPPORTUNITY ACT: If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact our Customer Service Manager at 333 33rd Avenue South, Saint Cloud, MN 56301 or 800-471-2122 within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for denial within 30 days of receiving your request for the statement. The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract); because all or 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. A number of federal agencies share enforcement responsibilities of this law. Determining which agency to contact depends on the type of creditor you dealt with. Consult the creditor to whom this application is addressed for information on its regulator, or contact The Federal Trade Commission, Consumer Response Center, Washington, D.C. 20580, 877-382-4357.

SIGNATURE

All information in this application and all attachments are correct to the best of my knowledge. I authorize Northland Capital and/or its lenders, participants and assigns to verify employment and all financial and other information submitted with this application, including obtaining a consumer credit report, to act on this application. I authorize such parties making continued inquiries about such information and obtaining a consumer credit report during the term of obligations. As required by law, my identity will be verified. I authorize all past or present creditors to release any and all necessary credit information, and to respond fully to requests for information based on this application when transmitted by electronic or other means. The above permissions and authorizations will apply to any creditor to whom this application is submitted. I certify that the obligations applied to hereunder are for business, commercial or agricultural purposes and not for personal, family and household purpose. I certify that authorization has been obtained from those listed above, however have not signed below, to obtain their consumer credit report as they are applying to Northland Capital for credit. I agree that Northland Capital and/or its lenders, participants and assigns may freely communicate credit, financial, transactional and other information about me in connection with the administration of any loan or lease. I agree that Northland Capital and/or its lenders, participants and assigns may freely communicate credit, financial, transactional and other information about me or any owner in connection with the administration of any loan or lease, including releasing credit bureau reports to lenders working with Northland Capital who may provide credit relating to this application.

FAIR CREDIT REPORTING ACT: If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, contact Customer Service Manager, 333 33rd Avenue South, Saint Cloud, MN 56301, 800.471.2122 within 60 days from the date of decision notification. A written statement of reasons for denial will be sent within 30 days of receiving request.

The Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract); because all or 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. A number of federal agencies share enforcement responsibilities of this law. Determining which agency to contact depends on the type of creditor you dealt with. Consult the creditor to whom this application is addressed for information on its regulator, or contact The Federal Trade ommission, Consumer Response Center, Washington, D.C. 20580, 877.382.4357.

Applicant Authorization

First Name*

Last Name*

E-mail*

Authorization*

I agree to this credit application and authorization release