Midwest Inbound Transport

Credit Request Form

Get " Set Up" Right away!  Just print this form, fill out completely and fax it to 651-430-9388.  We will then quickly process this and move your freight.  Without this form filled out we cannot move your freight.

Today's date:__________________

Contact:_____________________________________

Company Name:_______________________________

Address:_____________________________________(Billing Address)

City:________________________, State:____, Zip:______________

Phone:_______________________________________

Fax:_________________________________________

Email:________________________________________

Year Established:__________ Credit Amount Requested :_______________

Payment Terms:______days   Bankruptcy:___yes, no___, Date:__________

Notes:_________________________________________________________

List 4 trade references - Company, City, State & Phone Numbers

Company:

 

Company:

 

Company:

 

Company:

 

City/State

 

City/State

 

City/State

 

City/State

 

Phone:

 

Phone:

 

Phone:

 

Phone:

 

Your Signature :__________________ Your Company Name :___________________

Your signature authorizes the release of credit information on your company from the listed references above and confirms that information on this form about your company is accurate to the best of your knowledge.

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