Credit Application - MDB Trucking

Legal Name:*

Phone Number*

Trade Name (DBA):*

FAX Number:*

Billing Address (if different)

Street Address City State / Province / Region ZIP / Postal Code Country

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Person to contact regarding financial matter:*

Title:*

Type of Business:*

Years in Business:*

Parent Company Name and Address (if Branch, Subsidiary or Division)*

Select*

Propertiership
Corporation
Limited Partnership
Partnership
Ltd Liab. Corp.
Government

Incorporated in State of:*

Federal Tax ID:*

Bank Reference

Bank Name & Branch:*

Contact Number:*

FAX:*

Account Number (Checking):*

Account Number (Loans):*

Bank Name & Branch:*

Contact Number:*

FAX:*

Account Number (Checking):*

Account Number (Loans):*

Trade Credit Reference

Name:*

Telephone No:*

FAX No:*

Account #/ Contact:*

Name:*

Telephone No:*

FAX No:*

Account #/ Contact:*

Name:*

Telephone No:*

FAX No:*

Account #/ Contact:*

Officers/Principals of Company

Name:*

Home Address:*

Social Security No:*

Title:*

Ownership(%):*

Name:*

Home Address:*

Social Security No:*

Title:*

Ownership(%):*

Name:*

Home Address:*

Social Security No:*

Title:*

Ownership(%):*

I understand and agree to the following credit terms*

PURCHASES: I agree that all invoices must be paid in full on or before the 10th day following data of invoice. To induce prompt payment of the purchase price, a servioe charge In the amount of 1 1/2 per month (18% APR) of the amount due shall be paid by the purchaser.

ATTORNEY FEES: I agree that if this open account Is past due and placed In the hands of an attorney for collection to pay such additional sum as reasonable attorneys' fees for collection assistance whether or not a suit or action is instituted, and If a suit or action is instituted to collect any past due amounts. I agree to pay such additional sum as may be adjudged as reasonable attorneys' fees by the appropriate trial or appellate count.

I warrant the information shown above to be true. I authorise the person to whom this application is submitted to investigate the references herein statements, or other data obtained from me or from any other person pertaining to my credit and financial reaponolbIllty,

I agree