Credit Application - 7/30/2010

Information
(All fields in red must be completed to insure correct processing of your application)

Company:

Contact Name :

Billing Address:
City: State: Zip:

Special Billing Requirements: Auto Pay EDI Fax

Paperwork Requirements:

Accounts Payable Contact:

Accounts Payable Primary #:

Accounts Payable Fax #:

Accounts Payable Email Address:

Carrier Reference:

Carrier Contact :

Carrier Phone #:

Carrier Address:
City: State: Zip:

Company Reference:

Company Contact :

Company Phone #:

Company Address:
City: State: Zip:

Company Reference 2:

Company Contact :

Company Phone #:

Company Address:
City: State: Zip:

Bank Reference:

Bank Contact :

Bank Contact Phone #:

Federal ID:

*PLEASE READ CAREFULLY BEFORE SUBMITTING*

I understand that the information listed is accurate and true to the best of my knowledge and hereby agree / authorize Maverick Transportation to run an Experian Credit report and also authorize them to contact Carrier References listed above. I also understand that if credit is granted that the terms of this credit agreement will be on a net 30 day term from date of invoice. In the event that the amount of credit extended is placed for collection I understand that I will be responsible for all collection costs to include applicable attorney’s fees that may be incurred by Maverick Transportation LLC.

I certify that I have read the terms and conditions printed above