Application for Service

     

 

Billing

Address

 

__________________________________________________________________________________________

                 NAME OF FIRM OR INDVIDUAL

 

_________________________________________________________________________________________________________   

                                 ADDRESS                                                                                                                                                 YEARS AT THIS ADDRESS

                                                        

_________________________________________________________________________________________________________

CITY                                                 STATE                        ZIP                                                                                PHONE NUMBER 

    

_________________________________________________

CONTACT

 

                                The following information must be provided. It will be held in the strictest confidence.

                               

                               

Ownership          ___ CORPORATION ___ INCORPORATED IN LAST 12 MONTHS  ­­___ PARTNERSHIP  ___ INDIVIDUAL

 

 

­­­­­­­­­­­­­­­­­­­­_______________________________________________________________________________        ______________________

NAME (S) OF PRINCPAL (S)                                                           ADDRESS                                           PHONE NUMBER

 

_______________________________________________________________________________        ______________________

 

_______________________________________________________________________________        ______________________

 

Banking

 

_________________________________________________________________________________________________________

BANK                                                                                  BANK ADDRESS

 

_________________________________________________________________________________________________________

BANK OFFICER OR DEPARTMENT                               PHONE NUMBER

 

Business

References

 

_______________________________________________________________________________        ______________________

BUSINESS NAME                                  CUSTOMER  # OR  ACCOUNT #                                              PHONE NUMBER

 

_______________________________________________________________________________         _____________________

 

_______________________________________________________________________________        ______________________

 

_______________________________________________________________________________        ______________________

 

 

We certify that all information on this form is correct. We fully understand your credit terms and agree to the proper
 payment in consideration of extended credit.

 

 

Date_________ 20___                                (Name) ______________________________

 

                                                                           (Title)  ______________________________

 

 

We at Dart Couriers, Inc. would appreciate you taking a few moments to complete the following questionnaire. This will
 help us setup your account with the information your firm requires.

 

 

1.        Is your shipping address different from your billing address? ___Yes ___No     If “Yes” complete

 

       Address:______________________________________

 

       City:_________________________State:___________Zip:_________

 

       Contact:__________________________Phone:___________________    

                                                                               

2.        How did you hear of Dart Couriers, Inc.? _______________________________________

 

3.        Are there any special instructions that we need to be aware of? (i.e. deliver to side door) ___Yes ___No

 

       _______________________________________________________________________________________

 

       _______________________________________________________________________________________

 

4.        Will any of your deliveries require a truck? If “Yes”, the Customer Service Representive will ask if a truck is required at
 the time the order is placed. ___Yes ___No

 

5.        If we need to contact your firm after hours, is there a special phone number or extension that we need to be aware of?

___Yes ___No    If “Yes” enter information below

 

       _______________________________________________________________________________________

 

6.        What type of business does your firm operate? _________________________________________________   

           

7.        Does your firm require any type of Reference or P.O. Number? ___Yes ___No                 

If “Yes” describe: (i.e. GF#123456, P.O.#123456) 

 

       ________________________________________________________________________________________

 

8.        Will any of your deliveries require drivers to collect a COD amount from your customer?

 

       ___Cash Only   ___Cash/Check   ___NO 

 

9.        Additional information that you feel we need to be aware of:

 

_________________________________________________________________________________________

 

       _________________________________________________________________________________________

 

_________________________________________________________________________________________

 

       _________________________________________________________________________________________

 

 

 

Note: Your billing copy will include the delivery information. You will not receive a copy of the delivery receipt
   unless requested.