Open an Account


REQUESTED BY: (in red are required)
Name
Company Name
 
Telephone
 Fax
Street Address
City
 		State
 		Zipcode

BILLED TO:
Name
Company Name
 
Telephone
 Fax
Street Address
City
 		State
 		Zipcode
 
Yes, I would like a billing reference indicated
on my invoice:

IE: Project number, Client #, Case #,Etc...)
Type of Ownership
Corporation
Partnership
Proprietorship
How did you hear about us?

Nature of Business 
 
Credit Limit Requested
 Avg. Deliveries per Month
HISTORY/CREDIT INFO
Bank Acct#
 Tax ID
Bank Name
 
I understand and agree to the following terms:
The above is true and submitted for the purpose of opening an account.
This will authorize Express Connection to verify the above information.
This account will be billed twice a month and payment is due on receipt.
Your Name and Title: (Please Print)
 Owner/Company Officer's Name and Title: Date: