Credit Application

COMPANY INFORMATION

Company Name*

Name of Requestor*

Telephone*

Fax

Address Line 1*

Address Line 2

D & B Number

MC Number (if motor carrier or transportation broker)

BILLING INFORMATION

Accounts Payable Contact*

Telephone*

Email

Fax

Invoices to be sent to the previous address?* Invoices to be sent to the previous address?* Yes No (fill in information below)

Billing Address Line 1

Billing Address Line 2

Telephone

Email

Fax

BUSINESS INFORMATION

Business Type* Business Type* Proprietorship Partnership Corporation LLC Subsidiary

If Subsidiary, Parent Company

Location*

Phone*

Corporate Officers/Owners

Name*

Title*

Name

Title

Credit Information

Approximate Number of Loads Per Week

Bank Reference

Bank Name*

Contact Name*

Contact Phone*

Bank Address Line 1*

Bank Address Line 2

Trade References (Please include at least one truckload carrier)

Reference 1 - Name*

Address Line 1*

Address Line 2

Contact*

Type of Service/Product Rendered*

Telephone*

Fax

Reference 2 - Name

Address Line 1

Address Line 2

Contact

Type of Service/Product Rendered

Telephone

Fax

Reference 3 - Name

Address Line 1

Address Line 2

Contact

Type of Service/Product Rendered

Telephone

Fax