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Interstate Courier Express Credit Application

*Company Name

Billing Address

Physical Address

*Email Address

*Phone Number

Fax Number Credit amount Requested

Person Requesting Credit: Name Title

Type of Business Years in Operation

Parent Company

Division of Subsidiary of

Corporation Sole Proprietorship Partnership

DUNS#

Principals/Officers of the Firm : (Name, Title, Address, SS#)

Bank Reference : (Name, Address, Account #, Phone)

Checking

Saving

Loan Amount

Trade/Supply Credit References : (Name, Address, Account #, Phone)

We hereby authorize the above listed bank and Trade References to release information to Interstate Courier Express Inc. for use in evaluation of this freight account request

Requesting Officer		Signature
Title :		Date

Request Info

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Interstate Courier Express Credit Application