Legacy Financial Application

Upon submission of form, you will still be required to submit a copy of Articles of Incorporation, proof of insurance (Legacy Financial Services listed as a certificate holder), copy of authority, Copy of W-9 with Federal ID Number or Social Security Number if DBA, voided check, copy of drivers license and social security card.

Name Name First Last
Business Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Do you use a PO Box?

Do you use a PO Box? YES NO
PO Box Number PO Box Number
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Phone Phone - ### - ### ####
Mobile Number Mobile Number - ### - ### ####
Fax Fax - ### - ### ####
Federal ID#
Date of Birth Date of Birth / MM / DD YYYY
MC #
DOT #
Type of Trucking
Spouse's Name
Does this business use a DBA Name?

Does this business use a DBA Name? YES NO
State of Incorporation
Monthly Sales Volume $
Number of Trucks
How did you hear about our company?
This serves as my permission for the release of any information regarding this
application for the purpose of credit investigation of the company I represent or
for myself. Please begin the verification and remittance address change process
for the accounts receivable submitted to you in order for us to qualify as a client.
The above statements are true and accurate to the best of my information and
belief.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Printed Name and Date