Quote Cart

General Information

Physical Office Address
Entity Type
Company (Enter the number of each below)

Ownership and Key Personnel

Have you ever filed for Bankruptcy?
Are you a defendant in any Lawsuits?
Do you owe the Federal or State Government any taxes?
Have you ever been convicted of a Felony or Misdemeanor?

By signing below, I certify that the information contained herein and all forms and documents provided in connection herewith are true and correct. I further certify the information contained herein is submitted for the purpose of purpose of procuring, establishing and maintaining a financing facility on behalf of an entity in which the undersigned is an owner, officer and/or director and/or on whose behalf the undersigned may either severally or jointly execute a guaranty in favor of Convoy Capital, LLC (“Convoy Capital”) and that the financing facility is for business or commercial purposes only and the proceeds will not be used for any personal, family or household purposes. I authorize Convoy Capital to make whatever credit inquiries that it deems necessary in connection therewith and to obtain consumer reports or investigative consumer reports which may contain public record information about me, including but not limited to consumer credit, criminal records, driving record, education, prior employer verification, and worker compensation claims. These reports may include information regarding past employment experience along with reasons for termination of past employment. I understand Convoy Capital may request information from various Federal, State, local and other agencies which contain my past activities. I understand I have the right, within a reasonable time, to request from the agency(s) providing information a disclosure of the current information on file. I understand the agency(s) will require proper identification and the payment of any authorized fees prior to disclosure. I further authorize procurement of the reports mentioned above at any time during my contractual obligation to Convoy Capital as it is deemed necessary.

Typing your Name in the above Box provides your Legal Signature

Background Information and Release

Are there any delinquent Federal or State Taxes?
Has the Company ever filed for Bankruptcy or had a petition in bankruptcy filed against the Company?
Is the Company engaged in, or threatened with any litigation?
Has the Company had a financing/factoring relationship in the past 2 years?
Fuel Card Service

The undersigned certifies that this application and the information contained herein is submitted for the purpose of procuring, establishing and maintaining a financing facility for business or commercial purposes only and the proceeds will not be used for any personal, family or household purposes. By signing and submitting this Application, the undersigned certifies that the information contained herein, and all forms and documents provided in connection herewith, are true and correct, and that the undersigned is duly authorized by company to submit this application.

Authorization to Release Information

hereby authorizes Convoy Capital, LLC to obtain oral or written credit reports, credit risk scores and other enhancements to my credit report from any credit reporting agency, to verify my bank account balance(s) and or outstanding credit notes, to make any other inquiries pertaining to my qualifications for requested credit that it deems necessary or desirable, and to release to Convoy Capital any and all information which will assist in its credit investigation.

The undersigned being duly authorized by this organization hereby authorizes without reservation, any party or agency contacted by any representative of Convoy Capital to furnish the information mentioned above. This authorization may be reproduced to acquire references from more than one source and I acknowledge that a telephonic facsimile, photographic or email copy of this release shall be as valid as the original.

Typing your Name in the above Box provides your Legal Signature

The federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the FTC Regional Office for the Southeast Region of the Federal Trade Commission, which is located at the following address: 225 Peachtree Street NE, Suite 1500, Atlanta, GA 30303 or also the Federal Trade Commission, Consumer Response Center, Washington, DC 20580. If we take adverse action you have a right to a statement of specific reasons for the adverse action if you request such statement within 60 days from Convoy Capital, LLC at the address and telephone number given on this application. The written statement shall be sent to you within 30 days. Adverse action may include refusal to grant credit in substantially the amount or terms requested, termination or an unfavorable change in the terms of an account and refusal to increase the amount of credit available.