Your Hale Salesperson:
Business Name:
Address:
City, State, Zip:
Business Phone #:
Mobile Phone #:
Email:
Web Site URL:
Entity Type:	Corporation | Sole Proprietorship | Partnership | LLC
Tax ID #:
Business Started:

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Principal Information

Name:
Address:
City, State, Zip:
Social Security #:
Date of Birth:
Home Phone #:

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Name:
Address:
City, State, Zip:
Social Security #:
Date of Birth:
Home Phone #:

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Credit References

Name:
Phone #:
Contact:

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Name:
Phone #:
Contact:

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Trade References

Name:
Phone #:
Contact:

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Name:
Phone #:
Contact:

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Banking References (Checking, savings, retirement accounts)

Name:
Phone #:
Checking #:

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Name:
Phone #:
Savings #:

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Insurance Information

Agency:
Address:
Contact:
Phone #:
Ins. Co.:
Policy #
Expiration:

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Hauling Information

Products Hauled:
Hauling Area:

Company Hauling For:
Phone #:
Contact:

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Equipment Owned

# of Trucks

# of Trailers

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Nearest Relatives (Please list two)

Name:
Phone #:

Name:
Phone #:

Authorization for Release: I authorize Hale Trailer Brake & Wheel, Inc., any/or any credit party with whom Hale may work to conduct inquires regarding applicant's business operations and individual and business credit histories as it may deem necessary including, without limitation, requesting credit bureau reports, contacting banks, secured lenders, lessors and trade creditors for references and for information on Bank accounts, Loans, or Leases.