Exact Legal Name of Company MC#
Trade Name/DBA
Physical Address City State Zip
Billing Address (if different) City State Zip
Telephone # Fax # Cell#
What product do you haul? Current Monthly Volume
Anticipated Monthly Volume Trucks Owned Number of O/O or Leased Trucks
Full Name Title % of Ownership
Social Security # Home Phone #
Home Address Own Rent
City State Zip County
Date of Birth Driver's License # State
Spouse's Full Name Spouse's Social Security #
Are any Federal or State Tax Liens filed or threatened? Yes No
Are the company's Accounts Receivable pledged to any party? Yes No
I/We have been told and do understand that the submission of an application for Financial Services with Steelhead Finance ("Steelhead") does not mean that Steelhead will provide any financial services whatsoever. I/We further have been told and do understand that approval may come only after the management of Steelhead approves said application and the financial services offered are approved in accordance with the terms of Steelhead's Agreement with Client. The information supplied in this Application and all forms and documents submitted to Steelhead in connection herewith are true and correct to the best of my/our knowledge and belief. I/We understand that I/We may be responsible for any hard costs associated with processing this application. In support of this Application, Steelhead is hereby authorized to obtain personal and business credit and/or financial information from my/our bank(s), insurance company, accountant, and other financial institutions or commercial firms with whom I/We have done business as well as credit reporting agencies. It is understood that any such credit and/or financial information will be held in strict confidence and used only in consideration of this Application. As inducement for Steelhead to process this application, Applicant grants to Steelhead a security interest in their accounts receivables.
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