credit application

Secure Business Credit Application

Company Information

Legal Business Name: *

Federal Tax ID# *

MC/DOT Number *

DBA (if applicable)

Main Phone Number *

Email *

Company Street Address *

City *

State *

Zip Code *

Type of Business / Industry:

In Business Since *

If Division, Name of Parent Company:

In Business Since

Desired Equipment *

Quantity Needed *

Desired Term *

Remote Control/GPS Required *

Applicant / Representative Information:

Primary Company Principal Responsible for Business Transactions:

First Name *

Date of Birth *

Mobile Phone Number *

Zip Code *

Middle Name

Title *

Email *

Street Address *

Last Name *

Office Phone Number *

City *

State *

Credit History

Have you, your company officers or affiliates, or your company ever filed a petition in bankruptcy? *

Are you, your company officers or affiliates, or your company subject to any litigation? *

Have you, your company office or affiliates, or your company been subject to any collections or repossessions in last 7 years? *

If you answered yes to either of the above or have items negatively affecting your credit history which require explanation please provide that information here: *

Trade References

Institution Name *

Account # *

Phone Number: *

Street Address *

City *

State *

Zip Code *

Trade References 2

Company Name

Contact Person:

Phone Number:

Street Address

City

State

Zip Code

Acknowlagement *

I/We certify that all information entered in this application is true and complete. This request is for an Breeze Trucks billing account. I/We authorize Breeze Trucks to obtain further information concerning the credit and financial condition of the corporation, principal owner, proprietors, or partners; and to exchange or provide information with other credit grantors.

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