Please fill out the boxes below as completely as possible. 

Use the tab and shift tab keys to move around the form.

Firm Name

Billing Address

City State Zip

Street Address

City State Zip

Phone Ext.# Fax

E-mail

Type of Business

Ownership: Corporation  Partnership  Sole Proprietorship  Other

Federal ID# Duns#

Year Business Established Year Incorporated # of Employees

Corporate Principals/Partners/Owners

Name Title

Address

Name Title

Address

Affiliate Companies

Branch Offices

Credit References - please list five business references that you have done business with at least one year

Creditor Contact Name

Phone Ext.# Fax

E-mail

Street Address

City State Zip

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Creditor Contact Name

Phone Ext.# Fax

E-mail

Street Address

City State Zip

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Creditor Contact Name

Phone Ext.# Fax

E-mail

Street Address

City State Zip

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Creditor Contact Name

Phone Ext.# Fax

E-mail

Street Address

City State Zip

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Creditor Contact Name

Phone Ext.# Fax

E-mail

Street Address

City State Zip

_____________________________________________________________________________________

Financial Information

I (we) hereby authorize the release of information pertaining to checking account# , savings account# and any other accounts held at the following bank/lending institutions;

Bank Officer

Phone Ext.# Fax

Street Address

City State Zip

_____________________________________________________________________________________

Bank Officer

Phone Ext.# Fax

Street Address

City State Zip

I (we) certify that all the information on this form is true and correct. I (we) fully understand the credit terms and agree to the proper payment in consideration of extended credit.

Name Title

Signature ________________________________________________________ Date __________

PLEASE PRINT THIS FORM & FAX TO: 310-830-0930 - Thank you!

Copyright © 2000 REX Transportation. All rights reserved.
Revised: May 03, 2001 .