Please tell us about the equipment you are interested in (package, new, used, etc):

Have you spoken or emailed one of our salesman? If so, which one Select One Alan Rivera Philip Rivera Saul Valdez Steve Alden Tracie Rivera Any

We have three locations!  What location would you be purchasing from? Select One Donna, TX Boerne, TX San Antonio, TX Any

General Information:

First Name    M.I.   Last Name 

Email Address 

Social Security #   Date of Birth  

Current Address    

City State   Zip/Postal Code 

County    Telephone #  Yrs. At Address 

Marital Status Select One Married Unmarried Seperated   Have you ever used AAC  Select One No Yes

Name of Relative not living with you 

Address City  State

Telephone # Relationship

Co-Applicant's Information (If any):

First Name   M.I.   Last Name

Email Address 

Social Security #  Date of Birth 

Current Address    

City State   Zip/Postal Code 

County    Telephone #  Yrs. At Address 

Marital Status Select One Married Unmarried Seperated   Have you ever used AAC  Select One No Yes

Name of Relative not living with you 

Address City  State

Telephone # Relationship

Business Information:

If business is partnership or corporation, please provide information for all partners or officers below. If not being used for business or commercially, scroll down to green arrow and complete remaining form.

Business Name    Tax I.D.# 

Type of Business  Select One Individual Partnership Corporation Limited Partnership General Partnership Other

Business Address 

City State Zip/Postal Code

Years in business   

County & State in which equipment will be kept

CREDIT REFERENCES (MUST FILL OUT)

Employer 

City State Zip/Postal Code

Years  Annual Gross Income 

Other Income  Amount 

Other Income  Amount 

Complete the section below if over 25% of total income is from agriculture.  This includes farm or ranch use.  If not for farm or ranch, please mark individual/consumer use and continue down to the next green arrow.

Do you farm? Full time Part time Individual/Consumer

% of acres owned % of acres rented

Tell us about the financing you are looking for.

 Is the equipment you are wanting to finance new, used, etc...? Select One New Used Rebuilt Demo Unit

What brand name/make (primary item only if package) Tractor, Combine, Implement, etc...  Select One Agco/Allis Case/IH Century Ford Howse John Deere Kioti Knight Koyker Land Pride Long Massey Ferguson New Holland Rhino Int. Zetor

How many months would you like to finance your equipment?  Select One 12 Months 24 Months 36 Months 48 Months 60 Months 72 Months Other If other, please describe.

How much of a down payment towards your purchase (% of invoice)? Select One 5% of Invoice 10% of Invoice 15% of Invoice 20% of Invoice 30% of Invoice Other If other, please explain. 

Check below for type of financing contract desired.

Regular Fixed Variable Lease

Have I/we had any unsatisfied judgments rendered against me/us in the past 7 years, had equipment repossessed in the past 7 years, or been declared bankrupt in the past 10 years? Select One No Yes

Please include explanation if you answered yes to the above question or if you would like to share any other information that might aid in the completion of this application.

By selecting the submit button below, or signing with original signature, I (we) affirm that the information provided in this application, is true and correct and given for the purpose of obtaining credit and understand that if credit is extended.  Agricredit Acceptance LLC d/b/a Agricredit Acceptance Company, its agents, services, affiliates and assigns ("AAC Entities") will rely on such information to secure the indebtedness.  References are authorized to provide all relevant information to the AAC Entities.  The AAC Entities are authorized to investigate and obtain reports concerning my credit history and to release to, and share and exchange with, any other AAC Entities, any manufacturer of any equipment covered by this application and any  dealer submitting or originating this application any information concerning me, their credit experience with me and their decision whether or not to extend any credit.  I waive any right to confidentiality I may have with respect to the release, exchange or sharing of such information.

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Signature                                                                      Date

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Signature (Partner/Co-Signer/Guarantor)            Date