RENTAL APPLICATION

1

DRIVER INFORMATION

2

COMPANY

3

INSURANCE COMPANY

4

BANK INFORMATION

5

TRAILER INFORMATION

6

AUTHORIZATION AND CONSENT

NAME: *

First Name

Middle Name

Last Name

CUSTOMER *

New Customer Previous Customer

TYPE *

Company Driver Owner Operator

DRIVERS LICENSE NUMBER *

STATE *

HOME ADDRESS *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

FULL SOCIAL SECURITY NUMBER *

BIRTH DATE *

CELL *

Phone Number

E-MAIL *

example@example.com

How Did You Hear About Us? *

Next

NAME *

CONTACT NAME *

E-MAIL *

example@example.com

PHONE *

ADDRESS *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

DOT# *

MC# *

FEDERAL TAX ID# *

Next

NAME *

ADDRESS *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

CONTACT PERSON *

PHONE *

Phone Number

Next

REQUIREMENTS ARE AS FOLLOWS

Minimum liability limits of not less than $1,000,000.00 per occurrence and $2,000,000.00 annual aggregate. Operation of the Leased Property with bodily injury and property damage liability limits of not less than $750,000.00 per occurrence and $1,000,000.00 annual aggregate. Truck and Trailer Group, Inc., 1781 East Risser Street, Kankakee, IL 60901, must be named as Additional Insured for Liability and Loss Payee for Physical Damage

BANK NAME *

PHONE NUMBER *

Phone Number

ACCOUNT # *

Next

TRAILER(S) TO BE RENTED *

DESCRIPTION *

QUANTITY *

PICK UP DATE *

Next

AUTHORIZATION AND CONSENT

The information contained in this application is correct to the best of my knowledge.

I hereby authorize TRUCK AND TRAILER GROUP, INC., and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for rental application or purchasing purposes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences, employment history, education background, character references; civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm,corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to TRUCK AND TRAILER GROUP, INC., or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. TRUCK AND TRAILER GROUP, INC., and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers, and dates of birth.

SIGNATURE *

PRINT NAME *

DATE *

Submit

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"Thank you for your application. We will be in touch as soon as we review it."

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GT Express - Trailer Rental Division