New Client Questionnaire

Phone: (616)735-1500 Toll Free: (888)269-4743 Fax: (616)735-3950

1950 Waldorf NW, Ste C, Walker, MI 49544
New Client Questionnaire
The following information is needed to complete

Federal & State applications and forms.
Company Information:
LEGAL Name*
DBA Name
Contact Person*

First NameLast Name
Address*

Physical Address

Street Address Line 2

CityState

Zip Code
Company Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Email Address*
example@example.com
Other Contact #'s
Mailing Address (if different from above):

Address

Street Address Line 2

City State

Zip Code
Authority Type*

For HirePrivateBrokerNON-Trucking

List All Authorities Currently Held:
USDOT#
NY HUT#
MC#
NM#
KYU#
OR#
Federal ID#
IFTA Acct#
SCAC CODE
IRP #
List Each Partner and/or Owner:
Partner or Owner #1:
Title*
Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #*
Drivers License Number & State*
Date of birth*

MonthDayYear
Phone*

Area CodePhone Number
Partner or Owner #2 (if applicable):
Title
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #
Drivers License Number & State
Date of birth

MonthDayYear
Phone

Area CodePhone Number
Bank References
Bank Reference*
Bank Reference #1:
Name*
Address*

Address

Street Address Line 2

City / St ate / ZipState / Province

Postal / Zip Code
Bank Reference #2:
Name
Address

Address

Street Address Line 2

City / State / ZipState / Province

Postal / Zip Code
Safety Person At Your Company
Safety Contact Name*
Safety Contact Address (if different from above)
Safety Contact Title
Safety Contact Email*
example@example.com
Safety Contact Phone

Area CodePhone Number
Has your company ever had a Safety Review (audit)?*

YESNO
If yes, Date of Audit

MonthDayYear
Date
What was the rating?

SatisfactoryConditionalUnsatisfactory

Driver Information:

Please Enter the Number of Drivers in Each Category:

	INTERstate	INTRAstate
Within 100-Mile Radius
Beyond 100-Mile Radius

Total Drivers*
Total CDL Drivers*
Please List All Drivers

(Type Them Here or Attach a List Below If More Than Four)
Driver List is Attached (Name, Hire Date, License #)

Please Type Driver List Below: *

	Driver Name	Hire Date	CDL?	Driver License #
1
2
3
4

Truck Information:

Please Enter the Number of Vehicles in Each Category: *

	Straight Trucks	Truck Tractors	Trailers	Motor Coaches
Owned
Leased

Please List All Trucks

(Type Them Here or Attach a List Below If More Than Four)
Truck List is Attached (Unit#, Make, Year, VIN & GVWR)

Please List Each Vehicle Below: *

	Unit #	Make	Year	VIN	GVWR* (see note)
1
2
3
4

*Note: List the exact GVWR as indicated on the door tag on the driver's side door frame
Attach Driver and/or Truck List Here

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Provide Information on All Accidents in the Last 12 Months

(Either Attach a List or List Them Here)
Location
Driver's Names
Number of Injuries
Number of Fatalities
Number of Vehicles Towed

Please Provide WT Fleet Services With Copies of The Following Items:

If you cannot upload them, please check below to indicate how they will be delivered to WT Fleet Services and any other explanation needed.
If you are unable to upload any of the items below, please indicate how they will be delivered to us:

I am unable to upload and will email them to you at sales@wtfleet.comI am unable to upload and will fax the items to you at (616) 735-3950.I am unable to upload and will bring the items to your office.I do not have the items needed.Other
Articles of Incorporation, Organization or DBA Certificate

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Liability Insurance

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Title for each Truck & Trailer

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Registration for each Truck (Please provide Unit#'s for each unit)

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Annual Inspections for all Commercial Motor Vehicles and Trailers

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Heavy Vehicle Use Tax (Form 2290) for Each Truck Over 54,000 pounds

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ANY Certificates of Authority Currently Held

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Owners Drivers License

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WT Fleet Services can set up your company with Drug Screens Plus, as a courtesy to you.
Would you like WT Fleet Services to do this?*

YESNOAlready Enrolled
Proof of Enrollment in a Drug Testing Program, if applicable

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Any Additional Information We Should Know About You or Your Company?
Any Additional Files or Photos That We Need? Please Upload Them Here:

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Date Submitted

MonthDayYear
Please verify that you are a human*
Should be Empty:

New Client Questionnaire

Company Information:

List All Authorities Currently Held:

List Each Partner and/or Owner:

Bank References

Safety Person At Your Company

Company Operational Information

Driver Information:

Please List All Drivers

Truck Information:

Please List All Trucks

Provide Information on All Accidents in the Last 12 Months

Please Provide WT Fleet Services With Copies of The Following Items: