Name: Velocity Truck Centers
Telephone: 800-366-462

COMPANY INFORMATION

Company Name: *

Phone #: *

Fax#: *

Owners Name: *

E-mail: *

Address: *

City: *

State: *

Zip: *

Ship to address: *

City: *

State: *

Zip: *

Corporation - State Incorporated

Partnership

Sole Proprietorship

Other

DBA (if any): *

Type of Business: *

Year Business Started *

# of Trucks *

Current Los Angeles Freightliner customer: *

Which Company: *

PO Required?: *

Check to receive invoices via e-mail

Resale?

Yes

IF Yes, please attach a completed resale card

COD Application