Legal Business Name

Type of Business

Address

Subsidiary or Division of

Billing Address (if different)

Annual Revenue

City, State, Zip

Annual Income

Primary Office Address

Total Equity

President/Principal

Accounts Payable Contact

Dun & Bradstreet #

Website

Type of Business Type of Business Sole Proprietorship Partnership Public Corporation Private Corporation Other

Bankruptcy Bankruptcy Yes No

Date & Chapter

Phone

Fax

Date Established

Number of Employees

CFO/Controller

Federal ID #

Estimated Monthly Credit Requirement

A/P Phone

Email Address

SIC#

Name 1 Trade References (please include at least two motor carriers)

Address 1

Phone 1

Email 1

Name 2

Address 2

Phone 2

Email 2

Name 3

Address 3

Phone 3

Email 3

Name 4

Address 4

Phone 4

Email 4

Your Company Is: Your Company Is: Supplier Broker Other

Supplier Terms and Conditions Supplier Terms and Conditions Click this text to review Melton's Terms and Conditions. Please select "I agree" to continue. I agree

Broker Terms and Conditions Broker Terms and Conditions Click this text to review Melton's Terms and Conditions. Please select "I agree" to continue. I agree

Other (Please Specify)

Banking Name Banking Information

Phone

Address

Bank Officer

Account #

Name I hereby grant permission to the above referenced bank and credit references to release pertinent Information regarding our accounts to Melton Truck Lines, Inc. Furthermore, my signature attests to the financial responsibility, ability, and willingness to pay all transportation and related charges within 15 days of the date invoiced. SaveClear

Title

Date

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