Personal Information Driving Experience: Years Months First Name: Middle Initial: Last Name: Social Security #: Date of Birth: 00 12 11 10 09 08 07 06 05 04 03 02 01 / 00 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 09 08 07 06 05 04 03 02 01 / 0000 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 Email Address: Phone Number: Cell Phone: Present Address: Address Line 2: City: State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip:       License Information: License Number: Issuing State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming         Present / Previous Employer (1): Company Name: Position: Phone: From: 00 12 11 10 09 08 07 06 05 04 03 02 01 / 0000 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 To: 00 12 11 10 09 08 07 06 05 04 03 02 01 / 0000 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 City: State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming   Previous Employer (2): Company Name: Position: Phone: From: 00 12 11 10 09 08 07 06 05 04 03 02 01 / 0000 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 To: 00 12 11 10 09 08 07 06 05 04 03 02 01 / 0000 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 City: State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming   Previous Employer (3): Company Name: Position: Phone: From: 00 12 11 10 09 08 07 06 05 04 03 02 01 / 0000 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 To: 00 12 11 10 09 08 07 06 05 04 03 02 01 / 0000 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 City: State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming   Previous Employer (4): Company Name: Position: Phone: From: 00 12 11 10 09 08 07 06 05 04 03 02 01 / 0000 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 To: 00 12 11 10 09 08 07 06 05 04 03 02 01 / 0000 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 City: State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming   Questionaire : What is the name of the company you plan to lease your truck to? Would you like assistance in finding a good company to lease to: Yes No Other than lease or lease purchase, have you ever owned a truck before? Yes No   If yes, what was the date of purchase?   Who was the finace company? What is the name of your bank? Legal Actions (please check all that apply): Bankruptcy Judgements Lawsuits pending Voluntary or Involuntary Repos Tax Leans   Other Comments:   Applicant Agreement: As part of DaimlerChrysler's consideration of your application, they will investigate your employment background and your credit history. As part of this investigation, they may obtain consumer reports about you from several of the consumer reporting agencies. Any decision they make not to finance you based on information contained in your consumer report will be their decision alone. The consumer reporting agency and TSI does not make any decisions concerning financing with DaimlerChrysler and will not know the specific reasons why they may not decide to finance you. In the event you are not approved for a truck based on information contained in your consumer report, DaimlerChrysler will notify you by mail. You will also be advised of your right to obtain a free copy of the consumer report from the agency and your right to dispute the accuracy or completeness of your report. Consent for them to obtain your consumer report and employment history is required. Although you have a right to withhold your consent, DaimlerChrysler cannot consider your application if you do. I have read the above release and I give permission to obtain consumer reports about me. I have read the above release and I do NOT give permission to obtain consumer reports about me.