Alternate Delivery Solutions Service Request Form

  Name Of Company:  

  Physical Address:    

  Mailing Address :

  E-mail Address: 

  Phone:      

  City, State, & Zip:   

  Federal Tax I.D. Number:   

  Duns Number:        

  Fax Number:

  Corporation             LLP               Sole Proprietor          Partnership

 Account Customization

   Purchase Order      Job Reference         Required            N/A

  How many packages do you send on a daily basis?

  What are your company's hour's of operation?       

  Contact person:

   Do you need your Invoices sorted by reference number?   YES      NO

   Is there an after hour pick up or drop off  location?  

   Is your company internet able?  YES   NO               

   Will work orders be placed via the internet?  YES      NO

   Is there anything else we should know?               

Bank References

    Primary Bank:

   Account Number:

   Complete Address:

   Phone:

  Contact Person:

Trade References

  Reference #1 Name, Address, & Phone Number:

  Reference #2 Name, Address, & Phone Number:

  Reference #3 Name, Address, & Phone Number:

GENERAL TERMS & CONDITIONS & PERSONAL GUARANTEE

       Bills are sent on the first day of the month, although some accounts may receive weekly or biweekly invoice per agreement. All bills are due and payable within 30 days of invoice and if not paid within the time period are considered past due. All separate Overnight Delivery bills are due and payable within 15 days of invoice and if not paid within the time period are considered past due. No additional credit will be extended to past due accounts unless satisfactory arrangements are made with our credit department.

-- Please note credit card payments are taken via phone only --

       I represent that the above information is true and is given to induce to extend credit to the applicant. My company and I authorize Alternate Delivery Solutions to make such credit investigation as sees fit to obtaining credit reports. My company & I authorized all references, banks, & credit report agencies to disclose to any & all information concerning the financial & credit history of my company & myself. By submitting this application I  am agreeing to have read, understood the terms & conditions stated above & agree to all the terms and conditions set forth.

    Authorized Signature or Electronic Signature:  

Please E-Mail This Form Back To: deliverysolutions@mindspring.com

Or

Fax The Form Back To: (919) 882-1500