Online Credit Application

Printed Version

Legal Name*

Time in Business*

Best E-mail*

Best Phone*

Mailing address*

City*

State*

ZIP Code*

Physical address*

City*

State*

ZIP Code*

Business type*CorpLLCPartnershipSole proprietor

Fed ID/SS #*

State Inc*

DOT #*

IFTA #*

Monthly payment or rent*

How long?*

Ownership Company Structure

Accts. Payable Phone*

E-mail*

Fax #

Owner 1*

Title*

SS #*

Owner 2

Title

SS #

Owner 3

Title

SS #

Current Financial Summary

Cash*

Total Liabilities*

Net Worth*

Total Assets*

Net Income*

Bank(s)

Name*

Phone #*

Current balance*

Acct. #*

Name

Phone #

Current balance

Acct. #

Trade References

Name

Phone #

High credit

Acct. #

Name

Phone #

High credit

Acct. #

Insurance Information (Liability, Physical Damage, Loss Payee Required)

Name of Insurance Company*

Name of Insurance Agency*

Agency Address*

Contact*

City*

State*

ZIP*

Phone #*

Disclosure for all Applicants (Must provide an explanation to any Yes answers)

Owner or business ever file bankruptcy*YesNo

Month

Year

Owner or business ever repossessed*YesNo

Month

Year

Any equipment rental liens/judgements*YesNo

Month

Year

Explanation

*By checking this box I/we, for the purpose of obtaining credit, the undersigned hereby authorizes Renegade Equipment, Sales, & Consulting, LLC, or any of its agents or assignees to check the credit and employment history of the applicant and owners. I do hereby certify that the above information is true and correct to the best of my knowledge. The undersigned further certifies and agrees that the acceptance by Renegade Equipment, Sales, & Consulting, LLC of the Credit Statement in no way obligates Renegade Equipment, Sales, & Consulting, LLC to extend credit or to arrange credit for the undersigned. Renegade Equipment, Sales, & Consulting, LLC may deny the undersigned credit or assistance in obtaining credit for any reason or for no reason. Please note credit information and reports will be shared with the equipment Renter.

Print Name*

Date Signed*