Open an Account

REQUESTED BY: (in red are required)

Name
Company Name
Email
Telephone
 Fax
Street Address
City
 State
 Zipcode

BILLED TO:

Name
Company Name
Email
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 Account Number
 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:
 Owner/Company Officer's Name and Title:
 Date