New Customer Credit Application

Sales Representative:
Credit Limit Requested*:

Company Name*:
Tax ID Number:
Website:

Primary Contact/Title*:
Primary Telephone*:
Primary Fax:
Primary Email*:

Alternate Contact/Title:
Alternate Telephone:
Alternate Fax:
Alternate Email:

Physical Street Address:
Primary City:
Primary State:
Primary Zip:

Legal form under which business operates (circle one):C' CorporationS' CorporationPartnershipLLCProprietorshipOther

Other:
If division subsidiary, Name of Parent Company:
Type of Business:
Years in Business:
Current Freight Forwarder(s)Transportation Provider(s):
Type of Freight/Commodities you ship:
How frequently do you ship?:
Do you ship Hazardous Materials?:YesNo
Pickup Requirements - Are there any special requirements for pickup we should be aware of?:
Delivery Requirements - Will your freight deliver to multiple locations?:
If yes, how will you notify us of delivery instructions?:

Billing/Mailing Address:
Mailing City:
Mailing State:
Mailing Zip:
Individual or department responsible for payment of freight charges:
Mailing Telephone:
Mailing Fax:
Mailing Email:

Approximate Number of Shipments per Month:
Inbound:
Outbound:
Billing Requirments:
Invoices mailed or electronic?:
Bank Name:
Branch:
Account #:
Contact Person/Title:
Contact Telephone:
Contact Fax:

First Vendor Name:
Frist Vendor Contact Name:
First Vendor Address:
First Vendor City:
First Vendor State:
First Vendor Zip:
First Vendor Phone:
First Vendor Fax:
First Vendor Email:

Second Vendor Name:
Second Vendor Contact Name:
Second Vendor Address:
Second Vendor City:
Second Vendor State:
Second Vendor Zip:
Second Vendor Phone:
Second Vendor Fax:
Second Vendor Email:

Third Vendor Name:
Third Vendor Contact Name:
Third Vendor Address:
Third Vendor City:
Third Vendor State:
Third Vendor Zip:
Third Vendor Phone:
Third Vendor Fax:
Third Vendor Email:

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of credit to be extended. Furthermore, I hereby authorize the financial institution and vendors listed in this credit application to release necessary information to the company from which credit is being sought to verify the information contained herein.

Signature*:
Date*:

All information on this form will be held in the strictest confidence
Once application has been processed, we will notify you of application approval/denial, payment terms and credit limits.

New Customer Credit Application

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