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| TruckLend.com |North Shore Leasing & Funding Inc. d/b/a TruckLend.com | |
|[pic] [pic] | | |
| |PO Box 662 Attn: Charles | |
| |Smithtown, NY 11787 | |
| |(631) 231-3770 Fax (775) 306-7044 Cell (201) 400-8880 | |

|BUSINESS INFORMATION: |
|EXACT LEGAL COMPANY NAME: |TERM (Months) |BUSINESS TYPE |
| | | |
| | |LLC |
| | |CORPORATION |
|DBA (if applicable) : |CONTACT PERSON: | PARTNERSHIP |
| |Mr./Ms | LP |
| | |SOLE -PROPRIETOR |
|MAILING/ BUSINESS ADDRESS: |Cell #: |
| |E-mail: |
|CITY/ STATE/ ZIP: |
|BUSINESS PHONE NUMBER: |BUSINESS FAX NUMBER: |
|BUSINESS DESCRIPTION |YEARS IN BUSINESS |FEDERAL TAX ID# |
| | | |
| |
|REFERENCE INFORMATION: |
|TRADE REFERENCES: |ACCOUNT # |CONTACT NAME & TELEPHONE NUMBER |
|NAME: | | |
|NAME: | | |
|BUSINESS BANK ACCOUNTS |ACCOUNT # |TELEPHONE # |OFFICER TO CONTACT |
|NAME: | | | |
|NAME: | | | |
| |
|PERSONAL INFORMATION: Include all owners to account for 100% of company ownership |
|PRINCIPAL |SOCIAL SECURITY # |TITLE & OWNERSHIP % % |HOME ADDRESS & TELEPHONE |
| | | | |
| | | | |
| | | | |

|EQUIPMENT INFORMATION: |
|TYPE OF EQUIPMENT: |EQUIPMENT COST: |
| | |
| | |
|NEW USED REFURBISHED IF USED OR REFURBISHED - AGE OF EQUIPMENT: |
|SUPPLIER: |CONTACT: |PHONE: |
|SUPPLIER ADDRESS: |E-MAIL: |CELL #: |
| | | |

AUTHORIZATION TO OBTAIN CREDIT INFORMATION
Applicant warrants all credit and financial information submitted to North Shore Leasing & Funding, Inc. dba TruckLend.com.(here after referred to as TruckLend.com.) and/or its assignees to be true and accurate and hereby authorizes all banking institutions and credit reporting agencies to release necessary information via telephone, mail, Internet or facsimile as requested for purposes of making a credit decision. The undersigned individuals specifically authorize TruckLend.com Inc. and/or it assigns to obtain personal credit bureau reports for the making, extension, or renewal of this credit decision or collection of the resulting account. A fax or photocopy of this authorization shall be valid as the original.

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