Name: Required! Address: City: State/Province: Postal/ZIP Code: Contact Person: Required! Phone: Fax: E-mail: Required! Credit Limit Requested $: Lenght of Time in Business: Payables: Person to Contact: Title: Phone: Bank Name: Branch: Bank Account Number: Bank Contact: Title: Phone: Bank Address: Trade References: (Minimum of 3 are required, 2 must be carriers) 1. Vendor Name: Address: Fax: Phone: E-mail: 2. Vendor Name: Address: Fax: Phone: E-mail: 3. Vendor Name: Address: Fax: Phone: E-mail: 4. Vendor Name: Address: Fax: Phone: E-mail: 5. Vendor Name: Address: Fax: Phone: E-mail: Special Billing Information: POD Required: Yes No Shipper BOL: Yes No E-mail Invoice: Yes No E-mail: Send Invoices to the Attention of: THIS IS NOT A PERSONAL GUARANTEE: I hereby represent that I am authorized to submit this application on behalf of the customer named above, and that the information provided is for the purpose of obtaining credit and is warranted to be true. I/we herby authorize Berry and Smith Trucking Ltd. to investigate the references listed pertaining to my/our credit and financial responsibility. It is agreed and understood that all necessary collection, legal expenses and interest may be charged to debtor in the event of default. I/we further represent that the customer applying for credit has the financial ability and willingness to pay all invoices with established terms. Additional Information: Send