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Service Address

Company Name:________________________________________________________________

Address:______________________________________________________________________

City:____________________________________________ State:_______ Zip:______________

Phone:__________________________________ Fax:__________________________________

E-mail Address:______________________________

Billing Address: (if different)

Company Name:________________________________________________________________

Address:______________________________________________________________________

City:____________________________________________ State:_______ Zip:______________

Phone:__________________________________ Fax:__________________________________

E-mail Address:______________________________

Company Information

Type of business:_______________________________________ How long?______________

Sole Ownership_____ Partnership_____ Corporation_____

Principal:___________________________________ Title:______________________________

Bank Information

Bank Name:______________________________ Contact:______________________________

Address / Branch:_______________________________________________________________

Bank Phone:______________________________ Account #_____________________________

"The undersigned hereby gives permission for the release of information regarding the above-referenced account"

Trade References

Co. Name:________________________________ Acct #_______________________________

Address:__________________________________ Phone #_____________________________

Co. Name:________________________________ Acct #_______________________________

Address:__________________________________ Phone #_____________________________

Co. Name:________________________________ Acct #_______________________________

Address:__________________________________ Phone #_____________________________

TEAM DELIVERY SYSTEMS, INC. WILL NOT BE RESPONSIBLE FOR THE COST OF ANY ITEM NOT DECLARED AT THE TIME THE ORDER IS PLACED. OUR LIMIT OF LIABILITY IS 100.00 PER DELIVERY.
(The above information is submitted for the purpose of opening an account of which payment is guaranteed by the undersigned.)

Signed: ______________________________________________

Title:____________________________ Date:________________