Customer Application for Credit - To be Completed Prior to Shipping
Company Information:
President:		Controller:
Company Name:		Other Divisions:
Address:		Address:
City:		City:
Province/State:	Province/State Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Northwest Territories Nunavut Ontario Price Edward Island Quebec Saskatchewan Yukon --------------------- Alabama Alaska Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Province/State:	Province/State Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Northwest Territories Nunavut Ontario Price Edward Island Quebec Saskatchewan Yukon --------------------- Alabama Alaska Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Postal Code/ZIP:		Postal Code/ZIP:
	Public Private
Financial Information:
References
Company Name: Contact Name: City: Telephone#: Fax#: 1. 2. 3. 4. 5.
Banking Information
Bank Name:		Bank Account#:
Address:		Contact's Name:
City:		Telephone#:
Fax#:
Years of Operation:		Projected Monthly Freight Expenditure:
Customer Credit Limit Requested:		Customer Credit Terms Requested:	Days
Billing Information:
Accounts Payable Contact:		Bill to Name:
Telephone#:		Address:
Fax#:		City:
Province/State:	Province/State Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Northwest Territories Nunavut Ontario Price Edward Island Quebec Saskatchewan Yukon -------------------- Alabama Alaska Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Postal Code/ZIP:
Type of Billing
Once Weekly (Docket) Individual Invoice per Shipment   CDN$ US$
Terms and Conditions:
The Costomer agrees that in the event Fastrek Express Inc. incurs any expenses collecting past due invoices that the customer will re imburse all legal, collections or other expences incurred during this process. Fastrek Express Inc. is authorized to obtain credit information on the above company. I am an employee of the above mentioned company and have the authority to issue a credit check to Fastrek Express Inc.
Name: Title:
Signature: