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ONLINE APPLICATION

LEGAL BUSINESS NAME

BUSINESS ADDRESS

Street Address

Address Line 2

State

City

ZIP Code

PHONE

EMAIL

MC NUMBER

DOT NUMBER

TOTAL NUMBER OF TRUCKS

DO YOU CURRENTLY HAVE A FUEL CARD?

Yes No

HOW MUCH FUEL DO YOU PURCHASE PER MONTH? US GALLONS

HOW MUCH FUEL DO YOU PURCHASE PER MONTH? CAD LITERS

DO YOU CURRENTLY HAVE OR HAVE YOU APPLIED FOR BROKER AUTHORITY?

Yes No

TOTAL ACCOUNTS RECEIVABLES

OFFICER / OWNER LEGAL FIRST NAME

OFFICER / OWNER LEGAL LAST NAME

TITLE

ADDRESS

Street Address

Address Line 2

State

City

ZIP Code

DATE OF BIRTH

SIN / SSN

OWNERSHIP PERCENTAGE

OFFICER / OWNER EMAIL

WHO REFERRED YOU TO US?

CONSENT

I authorize the eCapital Group of Companies to conduct such credit, legal and security searches it deems necessary and to immediately register notices of security interest, regardless of whether security documentation has been executed by the Customer

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