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