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Company Information
Name of Business: 
Phone:  Ext: 
Fax: 
Address: 
City/State/Zip:       
E-mail: 
Trade Name or DBA/AKA, if applicable: 
Web Site Address: 
Federal ID Tax #: 

Mailing/Billing Information
Address: 
City/State/Zip:       
Type of Business:  Corporation Partnership Individual
Years in Business:    D-U-N-S Number: 
Nature of Business: 
Is your Company publicly traded?:  Yes No
If so, what is the Company's symbol? 
Approx. # of Shipments Per Month:  Inbound:  Outbound: 
Billing Requirements: 
Does your company accept electronic invoicing?:  Yes No    Pay by:  EFT ACH
Individual or department responsible for the payment of freight charges: 
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E-mail: 
Please describe your approval process from receipt to release of payment*: 

Parent Company Information, If Applicable
Company Name: 
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Credit References
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Vendor Business Name: 

Phone: 
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Carrier Business Name: 
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Carrier Business Name: 

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*Please provide two carrier references. 

Bank Name: 
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Additional Information
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Has your Company ever had legal collection activity taken against it?  Yes No
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