CUSTOMER INFORMATION

Legally Registered Name

DBA Name

Street Address
(No P.O. Boxes)

City

State

Please Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming           Zip Code

Referred By

Primary Contact Name

Contact Phone Number

Ext.

Contact E-mail

Type of Business

Please Choose Proprietorship Partnership LLC/LLP S-Corporation C-Corporation Not For Profit Not Yet Registered

State of Organization

Please Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming

Years in Business

Please Choose New 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8+ Years

Federal Tax ID

DUNS #

CUSTOMER BORROWING/BANKING INFORMATION:

Institution Name

Account Number

Phone

Ext

Contact Name

Institution Name

Account Number

Phone

Ext

Avg. Daily Balance

PRINCIPAL INFORMATION

Principal Full Name

Title

Home Address

Street City

State Please Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip

Phone

% Ownership

Social Security #

Principal Full Name

Title

Home Address

Street City

State Please Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip

Phone

% Ownership

Social Security #

VENDOR INFORMATION:

    Vendor Known             Vendor Unknown

Vendor Name

Address

Street City

State Please Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip

Vendor Contact

Phone Number

Fax Number

E-mail Address

Vendor Website

EQUIPMENT INFORMATION:

Equipment Description

Equipment Location

Street City

State Please Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Zip

Equipment Cost

Request Lease Term (months)

24
36
48
60
Other

By choosing 'I Agree', in the box below, the undersigned hereby certifies to Highline Capital Corp. and/or Highline Capital Transportation, Inc., including their respective successors and assigns (collectively, 'Highline'), that (s)he is, or is an authorized representative of, the customer identified in this Application ('Customer'), and has obtained proper written approval from any guarantor(s) of Customer's obligations to Highline, and any other principal(s) of Customer and such guarantor(s), and in such representative capacity and by virtue of such written approvals does hereby authorize Highline, to obtain credit information on Customer and guarantor(s), and all principals of Customer and/or any such guarantor(s), including without limitation personal consumer credit information, from any reporting agency selected by Highline to provide such credit information, and the undersigned and Customer agree to defend, indemnify, and hold Highline harmless from any claim or expense Highline may incur arising out of this certification being false, incorrect, or incomplete in any respect.

I Agree