General Information

Company:

Street Address:

City:

State:

Zip Code:

Country:

Phone:

Fax:

Billing Address:
Please fill out if different then street address above

City:

State:

Zip Code:

Credit Information

Structure: Corporation Partnership State of Filing Sole Proprietor

Social Society/Tax Id #:

Officer/Title:

Officer/Title:

Officer/Title:

Bank:

Account #:

Address:

City:

Zip Code:

Phone:

Bank Contact:

Has company ever filed for bankruptcy? No Yes

Any judgments’, liens or pending lawsuits? No Yes

Please explain any YES answer:

Credit requested?

Two carrier references:

1) Carrier:

Phone:

Been using carrier:

Monthly Volume:

2) Carrier:

Phone:

Been using carrier:

Monthly Volume:

Authorization

I agree
The above information is submitted in connection with our request to establish a credit account with Transportation & Logistical Concepts, “TLC”. Payment is required within 30 days from date of invoice. Any collection costs, including attorney fees will be added to unpaid invoices. Past due invoices are subject to a service charge on the outstanding balance calculated at a minimum rate of 1 ½ % per month. Any account exceeding the credit terms extended will automatically fall into a CASH only status, and will require payment in full to reestablish original terms. The filing of a cargo or other claim with the carrier will not relieve a payor from the responsibility for payment of freight charges. Freight charges must be paid before a claim is reviewed or honored. Returned checks will be subject to a $30 fee. All orders are subject to cancellation charges, including any and all costs incurred by, or charged to, “TLC.” The venue and jurisdiction for any dispute arising out of this agreement, and/or relationship between and the other parties to this agreement, including but not limited to, disputes over individual shipments, shall be brought in the Orange County Municipal Courts 1275 North Berkeley Avenue, Fullerton, CA. I/We have read this Credit Policy, and agree to abide by its terms.

By checking the I agree box and entering your Authorized Signature, I stipulate that I have the authority to, and do authorize inquiry as to bank & credit information. I further acknowledge that credit privileges, if granted, may be withdrawn at any time.

Authorized Signature
MUST BE AN OFFICER OF THE COMPANY OR PERSON AUTHORIZED TO SIGN

Title:

*Email:

Date

*Required