Working Capital

    Corporation name or DBA name

    Tax ID number or EIN Number

    If any

    Applicant's Date of Birth [Match with CDL]

    Commercial Driving License

    [Ex: 1 year and 8 months to be written as 1.8 yrs]

    [Ex: 1 year and 8 months to be written as 1.8 yrs]

    [Ex: 123 Abc St. APT# A]

    [Ex: Lathrop]

    Use Abbreviation of the States

    Always 5 Digits


    (Not living with you. No business related references such as freight broker or employer)

    [Ex: Lathrop, CA]

    [Ex: Lathrop, CA]

    [Ex: Lathrop, CA]

    Equipment Information

    Type Full Form - T680, Cascadia, VNL 800 etc

    [EX: 2022]

    Full Purchase price of the equipment

    Full Purchase price of the equipment

    Type : Additional if Buying first time or adding additional.

    Total number of Truck & Trailers client own and is in his name.

    Have client fill out the maximum downpayment here.

    [EX: 52,000]

    [EX: Cummins, Volvo, Detroit etc..]

    Employer Information

    [EX: Swift Transportation]

    Usually Dispatcher Contact name

    Best contact of the Employer

    The signer certifies that he/she is authorized to execute this Application for the named business (“Applicant”), and that all information and documents submitted, are true, correct, and complete. Applicant certifies that he/she has secured or applied for all applicable licenses or permits needed to conduct the named business. The signer authorizes Virsa Capital, Inc. and its partners to obtain consumer and/or business reports in their names as individuals at any time. The signer further agrees to notify Virsa Capital promptly of any material change in any such information. The signer authorizes Virsa Capital and its partners to contact references and request criminal record information from criminal justice agencies for the purpose of determining eligibility. The signer understands and agrees that this application is subject to final credit approval. The signer also agrees Virsa Capital can share information for marketing purposes with its partner companies and the applicant has the option to opt out from marketing anytime by contacting us at +1 516-859-6300
    or send email:

    The signer/Applicant acknowledges that Virsa Capital is a finance broker who assists borrowers of equipment financing in applying for an equipment loan with various finance lenders. Virsa Capital shall be sharing the Applicant’s personal and financial information with these lenders to receive quotes and help originate the equipment financing. Applicant acknowledges that Virsa Capital shall be charging Applicant a fee as agreed in a separate agreement in addition to Virsa Capital receiving any referral fees, origination fees, and other related fees from their vendor(s)/ partner(s The signer/Applicant agrees that Virsa Capital or its agent(s) does not owe a general or special fiduciary duty to Applicant under this brokerage relationship.

    First & Last Name