CREDIT APPLICATION Want to download a PDF form pdf version to print and fax? Download here >
APPLICANT INFORMATION
Legal Name: DBA Name:
Physical Address ( street, city, state & zip):
Business Phone:     Cell Phone:
Contact Name:     Title:     Email:
Federal Tax ID:    Years in Business:    # of Employees:    MC #:
Date of Incorporation:      State of Incorporation:        Parent Company (if applicable):  
Legal Structure:    Sole Proprietorship        Partnership        LLC        Corporation
CDL? Y N        Years as Owner Operator:     Years with CDL:   Are you a homeowner?: Y    N

LEGAL NAME OF OWNERS, OFFICERS OR GUARANTORS
(Principals with 20% or more ownership must be listed below)
Name 1:      DOB:     Email:
SSN:       % Owned:      Cell #:       Home #:
Years with Company:    Years Experience:
Home Address (please include street, city & zip):

Name 2:      DOB:     Email:
SSN:       % Owned:      Cell #:       Home #:
Years with Company:    Years Experience:
Home Address (please include street, city & zip):

Name 3:      DOB:     Email:
SSN:       % Owned:      Cell #:       Home #:
Years with Company:    Years Experience:
Home Address (please include street, city & zip):

EMPLOYMENT INFORMATION
Current Employer/Haul Source: How Long? Years:    Months:       Company Driver    Owner Operator
Contact Name:       Phone #:

Past Employer/Haul Source 1 (need 3 year history total):       Company Driver  Owner Operator
How Long? Years:     Months:

Contact Name : Phone #:

Past Employer/Haul Source 2 (need 3 year history total):        Company Driver Owner Operator
How Long? Years:     Months:

Contact Name : Phone #:

Future Employer/Haul Source:        Start Date:     Company Driver Owner Operator

OTHER INFORMATION
#Trucks:   #Trailers:     Haul Type:  Port     Local     48 - State    Regional, list states:
Is 51% or more of your business conducted in CA?    Y   N       Products Hauled:      Hazmat: N
Replacement Equipment:    Y    N          Annual Miles Driven:         Average Annual Gross Revenues:

EQUIPMENT FINANCE REFERENCES
Name of Finance Company/Cash Equipment (year, make & model) Original Balance Current Balance
       
AUTHORIZATION RESPECTING CREDIT INFORMATION
Customer and each proposed Guarantor authorize Crossroads Equipment Lease & Finance, LLC (“Creditor”), and Creditor’s designee(s) and assignee(s), to request, obtain and use information (including business and personal credit reports) concerning Customer and similar information concerning each Guarantor, from credit reporting entities, current and former customers and creditors of Customer and/or Guarantor, and banking, trade and other credit references. Customer and each Guarantor authorize Creditor to share all information so obtained with its syndication partners, funding sources, and affiliates. Customer and each Guarantor authorize all information providers to provide to Creditor, its designees and assignees, all information within the scope of this authorization. This authorization extends to the original request for financing; to all updates, renewals, extensions, modifications, and reviews of such financing or any extension of further credit; and to all collections of any resulting account. This authorization remains in effect until all obligations of Customer are paid in full. By signature below, each signer affirms such signer’s identity as the individual named in the application.
 
By checking this box and filling out your name in the signature field, I hereby acknowledge that it is in place of
your signature, and can be used as such.
 
10/17/2017
Applicant Signature Title Date
 
Co-Applicant Signature Title  
 
Co-Applicant Signature Title