Express Junk Removal Voice: (760) 489-6001 - Fax (760) 489-6401 Go To Page 2 >  Application For Commercial Credit Account Page 1 of 2 (You must submit both pages) Company Address & Contact Information
Company Name:_______________________________________ Phone:(     )___________________
Billing Address:________________________________________________________________________
Billing Address 2:________________________________________________________________________
Fax:(     )___________________________	City:_________________________________
State:_______ Zip Code:_________ Email:__________________________________
fill In This Section Only If Different From Above
Corporate Address:__________________________________________________________________
Phone:(     )___________________________ Fax:(     )___________________________
City:____________________________________ State:____________ Zip Code:___________
Tell Us About Your Company
Nature of Business:_______________________________________________________________________
Number of Years in Business:___________
DBA or Registered Trade Name:_____________________________________________________________
State of Corp:__________ Corp #:___________________ Federal ID #:____________________________
Date of Corp:___________  Ever Filed for Bankruptcy?  Yes  No
When? Month:____________ Year:__________ Chapter:_______________
Type Of Business Ownership
Sole Owner Signature: ______________________________ Social Security #:____________________________
Partnership Partner 1 Signature: ______________________________ Social Security #:_____________________
Corporation (Check one)
Type Of Corporation:  C Corporation  S Corporation    LLC
Officer Signature:_________________________________ Position:___________________________
Billing Instructions
Purchase Order Required?  Yes        No
Individuals With Authority to Sign Work Orders:________________________________________________
Credit Terms Requested:   7 Days   10 Days   14 Days   21 Days
Name of Person(s) Responsible for Signing Checks:_____________________________________________
Bank References
Bank Name:___________________________________________________________________________
Address or Branch:_____________________________________________________________________
City:________________________ State:_____________ Zip Code:_______________
Phone: (     )____________________________ Fax: (     )______________________________
Checking Account #:__________________________ Savings Account #:__________________________
For Internal Use Only
Credit Limit:___________ Date:________ Approved By:__________ Account #:_________________ Go To Page 2 >