Customer Billing Information - DOC by cua20830

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									                                  Customer Credit & Billing Information
Customer Name:_________________________________________________________________________

Physical Address:________________________________________________________________________

Billing Address:_________________________________________________________________________

City:_____________________ State:______________                      Zip:_________________________

Local Phone #(no 800):__________________________                     Fax #:_______________________

800#:_________________________________________                       www.________________________
Customer Contacts:
Operations:____________________________________                      Phone:_______________________

Accts Payable:_________________________________                      Phone:_______________________

Claims:_______________________________________                       Phone:_______________________
Customer Billing Requirements:
Need PO#         Y        N                                          Other Requirements :  Y      N
                                                                     _____________________________________
Payment:         Check________ EFT________                           _____________________________________
                                                                     _____________________________________

Certificates of Insurance requested ? Y             N                Certificate Attention:______________________
E-Mail or Fax:_________________________
Customer Credit Information:
Dun&Bradstreet #:______________________________                      Est. # of Loads/Week:__________

Est Rev./Week:_________________________________                      Year Business Started:__________

Does Customer have a Credit information sheet of their own ?   Y     N If yes, please attach.
Transportation References:
Name: 1)________________________           2)_______________________          3)_______________________

Address:________________________           _________________________          _________________________

City/State:_______________________         _________________________          _________________________

ZiP:____________________________           _________________________          _________________________

Phone:__________________________           _________________________          _________________________


LTL Management’s Credit Policy: LTL Management, LLC will bill customer at time of delivery. Payment is due within
15 days from the invoice date. By signing this credit application, the Customer acknowledges LTL Management’s Credit
Policy and agrees to it’s terms.

Customer’s Signature: __________________________________ Date: _____________________


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