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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 ProprietorshipPartnership
Principals/Officers of the Firm : (Name, Title, Address, SS#)
Bank Reference : (Name, Address, Account #, Phone)
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