Autrey

Company Name _______________________________________________________________________________

Address _____________________________________________________________________________________

City ____________________________________________

State _________

Zip ______________

Fed. ID#_________________________

Form Of Business Individual ____ Corp. ____ LLC ____

Yrs. In Business _____

Nature Of Business ____________________________________________________

Contact ______________________________________________________ Title ___________________________

Phone _____________________ Fax __________________ Email _____________________________________

OWNERS / STOCKHOLDERS

Name _______________________________________________________________ Title ___________________

Address _____________________________________________________________________________________

City _________________________________________ State ________ Zip _______________

SS# __________________________________ % Of Ownership ________ Yrs. Experience ____________

Name _______________________________________________________________ Title ___________________

Address _____________________________________________________________________________________

City _________________________________________ State ________ Zip _______________

SS# _________________________________ % Of Ownership ________ Yrs. Experience ____________

Name _______________________________________________________________ Title ___________________

Address _____________________________________________________________________________________

City _________________________________________ State ________ Zip _______________

SS# _________________________________ % Of Ownership ________ Yrs. Experience ____________

Have You Ever Taken Bankruptcy? No _____ Yes _____ Explain Below

Are You A defendant In Any Legal Action? No _____ Yes _____ Explain Below

Have You Ever Had Any Item Repossessed? No _____ Yes _____ Explain Below

Explanation: __________________________________________________________________________________

_____________________________________________________________________________________________

BANK REFERENCES

Bank Name ___________________________ Address _______________________________________________

Contact ___________________________ Phone # ________________ Account# _________________________

Bank Name ___________________________ Address _______________________________________________

Contact ___________________________ Phone # ________________ Account# _________________________

CREDIT REFERENCES (List all Credit References On Paid Accounts)

Name _______________________________ Contact ____________________ Phone _____________________

Account# ___________________________ Opened ________ High Credit __________ Balance ____________

Name _______________________________ Contact ____________________ Phone _____________________

Account# ___________________________ Opened ________ High Credit __________ Balance ____________

Name _______________________________ Contact ____________________ Phone _____________________

Account# ___________________________ Opened ________ High Credit __________ Balance ____________

INSURANCE / BONDING INFORMATION

Insurance Company ____________________________ Contact _______________________________________

Phone # _____________________ Liability Coverage ______________ Phys. Damage Coverage ____________

Bonding Company ____________________________ Contact _______________________________________

Phone # _____________________ Would You Like An Insurance or Bonding Quote? Yes ____ No ____

TRANSPORTATION COMPANY INFORMATION

# Trucks / Trailers Currently Running Trucks _____ Trailers _____ Off Hwy Use Yes ____ No ____

Average Length Of Haul Local ____ Regional ____ National ____ Products hauled ________________________

Haul Reference Name ____________________________ Contact ______________________________________

% of Your Revenue ________________ Phone ____________________________

Haul Reference Name ____________________________ Contact ______________________________________

% of Your Revenue ________________ Phone ____________________________

The undersigned certifies the above information is correct and by signing below, consents to the obtaining from credit reporting agency or credit grantor such information as Autrey Capital Group, L.L.C. may require at any time in connection with credit hereby applied for and consent to the disclosure at any time of any information concerning to any credit reporting agency or credit grantor with whom the undersigned has a financial relationship. The undersigned also certifies this application is for business purposes, not personal, family or household.

Authorized Signature(s) ________________________________________ Title(s) ____________ Date _________