Customer Credit Application

Sales Rep

Sales Rep Email

Strategic Partner

Referral Source

Customer Information

Business Type *

Company Legal Name *

DBA (Doing Business As)

Legal Physical Business Address *

Legal Physical Business Address 2

Country *

City *

State *

Zip Code *

Province *

Postal Code *

Business Phone Number *

Mobile Number

Business Fax Number

Employer Identification Number *

Leased On *

Is DOT Number Required by State *

DOT Number *

Is MC Number Required by State *

MC Number *

Harmonized Sales Tax Number (HST) *

Goods and Services Tax Number (GST) *

Provincial Sales Tax Number (PST) *

Fleet Size *

Number of OTR Trucks *

Account Information

Requested Credit Line: *

Bank Name *

Bank Account Owner Name *

Bank Routing Number *

Bank Account Number *

Attach Voided Check