Today's Date Business Start Date

Federal Tax ID # State of Incorporation

C-Corp S-Corp LLC Partnership Sole Proprietorship

Parent Company (if applicable)

Customer Legal Name

DBA Name

Address

City   State Zip Code

US DOT#   MC Number

Principal Owner/Guarantor  

Title

SSN   % Owned

Years w/company

Principal Owner/Guarantor  

Title

SSN   % Owned

Years w/company

Principal Owner/Guarantor  

Title

SSN   % Owned

Years w/company

Finance / Insurance Information

Bank Name Checking Account #

Contact Name Telephone #

Operating Line

Bank Name     Operating Line #

Contact Name Telephone #

Operating Line Secured by Accounts Receivable  All Assets Personal

Other    If other please describe

Vehicle Finance References x3 if applicable

1st Vehicle Finance Reference

Account #

Contact Name

Telephone #

2nd Vehicle Finance Reference

Account #

Contact Name

Telephone #

3rd Vehicle Finance Reference

Account #

Contact Name

Telephone #

Insurance Agency

Contact Name

Liability Coverage $

Physical Damage Coverage $

Telephone #

Major Customers

Name   % of Revenue How Long Years?

Contact    Telephone #

Name   % of Revenue How Long Years?

Contact    Telephone #

Current & Future Equipment Information

Current Fleet

Tractors Trailers

Future Fleet Information

Total # of trucks to be purchased/leased

# of additions   # of replacements

Fleet Segment

Dry Van-General Freight Truckload LTL Other

Nature of Business

Construction Agriculture Food/Grocery Refuse Mixer

Material Hauling Delivery Hazardous/Toxic Tow/Recovery

Tank Municipal Other    If other please specify

Annual Average truck mileage

Equipment Operates

Local Regional Interstate Intrastate

Type of Finance

Retail Trac Lease Fair Market Value Other

Balloon/Residual %

Your Fax #

Your E-mail address

AUTHORIZATION TO RELEASE CREDIT INFORMATION
The undersigned certifies that: (a) all of the information contained herein or provided in connection with this Application is true and correct and accurately describes the financial condition of the Customer(s) as of the date hereof; and (b) I will notify DCFS USA LLC and Daimler Trust, and their respective successors, transferees and assigns ("Creditor") if I become aware of any material change in the financial condition of the Customer(s). I hereby authorize Creditor and/or Dealer to make inquiry into, to request, and to receive any information concerning my financial condition, including, but not limited to, obtaining a credit report and contacting any current or former creditors of Customer(s) to verify any information contained herein or received in connection with this Application, which Creditor and/or Dealer deems relevant to the possible extension of credit to Customer(s) (“Information”). I also grant any such creditors permission to release Information to Creditor and/or Dealer. I authorize Creditor to disclose Information to any affiliate, assigns or agent. I authorize Creditor to file a UCC financing statement. I have applied for a loan, lease or extension of credit from Creditor and I intend to use the purchased Equipment primarily for business or commercial purposes, and not for personal, family, household or agricultural purposes. The foregoing provision shall remain in effect until Customer pays Creditor in full for all outstanding indebtedness under all loans, leases or extensions of credit (if Creditor decides to grant credit to Customer(s)).