Credit Application

Please complete, authorize and date this form.

BILLING INFORMATION

Billing Address *

Address Line 1

City

State

Zip Code

Accounts Payable Contact *

Accounts Payable Phone *

Accounts Payable Fax

Accounts Payable Email: *

BANK REFERENCE

Bank Name *

Bank Address *

Address Line 1

City

State

Zip Code

Bank Phone *

Bank Contact *

Bank Account# *

CREDIT REFERENCE

Credit Reference #1- Company Name *

Credit Reference #1- Address *

Address Line 1

City

State

Zip Code

Credit Reference #1- Account# *

Credit Reference #1- Contact *

Credit Reference #1- Phone *

Credit Reference #1- Fax

CREDIT REFERENCE #2 *

Credit Reference #2- Address *

Address Line 1

City

State

Zip Code

Credit Reference #2- Account# *

Credit Reference #2- Contact *

Credit Reference #2- Phone *

Credit Reference #2- Fax

CREDIT REFERENCE #3 *

Credit Reference #3- Address *

Address Line 1

City

State

Zip Code

Credit Reference #3- Account# *

Credit Reference #3- Contact *

Credit Reference #3- Phone *

Credit Reference #3- Fax

CREDIT TERMS AND CONDITIONS

CREDIT TERMS AND CONDITIONS *

I accept the terms of service below *

The undersigned authorizes inquiries to credit information. I/We further acknowledge that credit privileges, if granted, may be withdrawn at any time and certify the above information to be true. I/We also understand that all charges will be paid within the specified credit terms of Estafeta USA’ s Invoices.
The undersigned is advised and understands the benefits, coverage, terms and conditions of the Insurance offered by Estafeta USA, Inc. and also is aware of the waybill terms and conditions. If not advised in written to Estafeta USA, Inc., shipments will not include additional insurance.

Print Name *