must be of the same name - Carroll Fulmer Logistics Corporation

OWNER/EQUIPMENT INPUT SHEET Page: 10
THIS FORM MUST BE COMPLETED BEFORE PROCESSING
Owner’s Full Name: ___________________________________________________________
Owner’s Full Address: _________________________________________________________
City: __________________________________ State: ____________ Zip: _______________
Social Security #:______________________ Federal ID#_______________________________
Home phone#:_____________________________ Cell phone #______________________________
EQUIPMENT INFORMATION
Tractor
______________Physical Damage Insurance ____________ Bobtail Insurance
(check if needed) (check if needed) (If no, proof of insurance is required)
Year: ________ Make: __________ Color: ________ VIN #: _________________________________
Unladen Weight: _________________ License Plate#:_________________ State:________
Purchase Price: _________________________ Date of Purchase: ______________________
Current Tractor Value: _________________ Lienholder Name: ______________________
Leinholder Address: ______________________________________________________________
Phone Number: __________________________ Fax Number: __________________________
OWNER’S SIGNATURE:___________________________ DATE:__________________