​​​​​​​Truck Rental Credit Application 

Asterisk indicates Required Field
  • Customer Name
    *
  • Phone #
    *
    • Email
    *
  • Fax #
  • DOT #
    *
  • Physical Address
    *
    • City
    *
    State
    *
    Zip Code
    *
  • Bill To Address
    *
  • City
    *
  • State
    *
  • Zip
    *
  • Phone #
    *
  • Fax #
  • Sales Tax Excempt
    If yes
    • Upload your Resume
    *
  • Purchase Order Required
    *
  • Today's Date
    *
  • Date Business Commenced
    *
  • Type of Business
    *
  • Desired Credit Amount?
    *
  • Tax ID #
    *
  • Business Structure

Principal One

  • Name
    *
  • Title
    *
  • Address
    *
  • City
    *
  • State
    *
  • Zip
    *

Principal Two

  • Name
    *
  • Title
    *
  • Address
    *
  • City
    *
  • State
    *
  • Zip
    *

Principal Three

  • Name
    *
  • Title
    *
  • Address
    *
  • City
    *
  • State
    *
  • Zip
    *

Banking

  • Bank Name
  • Phone #
  • Contact Name
  • Bank Address
  • City
  • State
  • Fax #
  • Email
  • Zip

Insurance

  • Insurance Company
    *
  • Agent Name
  • Email
  • Phone #
  • Fax #
  • Expiration Date
  • PHYS Damage Deduct. $
    *
  • Liability Limit
  • Equipment Schedule?
    *

Credit Reference One

"Fuel vendors and COD Vendors are not acceptable"
  • Vendor
    *
  • Phone #
    *
  • Fax #
  • City
    *
  • Account #
    *
    • Upload Credit Reference
    • Upload your Resume

Credit Reference Two

"Fuel vendors and COD Vendors are not acceptable"
  • Vendor
    *
  • Phone #
    *
  • Fax #
  • City
  • Account #
    *
    • Upload Credit Reference
    • Upload your Resume

Credit Reference Three

"Fuel vendors and COD Vendors are not acceptable"
  • Vendor
    *
  • Phone #
    *
  • Fax #
  • City
    *
  • Account #
    *
    • Upload Credit Reference
    • Upload your Resume
    Select a location
    What Type of vehicle are you looking for?
    Amount of time to Rent
  • Number of units to be rented
    • Are you currently broken down and need to complete a delivery?

  • Where is the truck being worked on?
  • Is it at a Palmer Trucks dealership?
  • Approximate date the truck will be needed
  • Do you currently have a salesman you are working with? If so, please list their name

TERMS AND CONITIONS:

It is agreed that the buyer will pay all invoices in accordance with terms of net 10 days and interest will be assessed on delinquent invoices at the rate of 1.5% per month (18% per annum) together with all court costs, attorney’s fees of not less than 25% of the unpaid amount of principle and interest. This authorizes the release of any credit information. This Application, and related documents to this application are signed when a party’s signature is delivered by facsimile, email, or other electronic medium. These signatures must be treated in all respects as having the same force and effect as original signatures. By checking this box and/or clicking “Submit”, you are providing an electronic signature to the full effect of the terms prescribed herein. The buyer affirms that they are duly authorized to complete and sign this application and further verifies that all information is truthful and correct.

  • *
  • *