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I
nterstate
C
ourier
E
xpress 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