Part A: Business

Company Name:

Address:

Mailing Address:

Phone Number:

(###)

###

####

Type of Business:

Number of Years:

Fed Tax Number:

Has this firm or any of its Principals ever been bankrupt?

Yes

If yes, please explain:

Part B: Principals

Principal:

Name

Title

Principal:

Name

Title

Principal:

Name

Title

Part C: Vendor References

Vendor Reference:

Company Name

Contact

Phone Number

Email Address

Fax Number

Vendor Reference

Company Name

Contact:

Phone Number:

Email Address:

Fax Number:

Vendor Reference

Company Name:

Contact:

Phone Number:

Email Address:

Fax Number:

Part D: Bank References

Bank Reference:

Company:

Address:

Account Number:

Contact:

Bank Reference:

Company:

Address:

Account Number:

Contact:

Bank Reference:

Company:

Address:

Account Number:

Contact:

Part E: Payment/Billing Information

Email Address:

Email Address to send invoices to:

Do you utilize a third party payment agency?

(Cass, Coupa, Syncada, etc.)

Yes

If yes, which one:

Are there any particular vendor requirements to use this system?

If so, please email a copy to your sales representative.

Do your vendors have to pay a fee to use this service?

Yes

If yes, approximate percentage:

I represent that the above information is true and is given to induce Portland Air Freight Inc. to extend credit to the applicant. My company and I authorize Portland Air Freight Inc. to make such credit investigation as Portland Air Freight sees fit, including contacting the above trade references and banks and obtaining credit reports. My company and I authorize all trade references, banks, and credit reporting agencies to disclose to Portland Air Freight Inc. any and all information concerning the financial adn credit history of my company.

Further, I understand that Portland Air Freight Inc. has credit terms of Net 30 from the date of invoice. Portland Air Freight Inc. reserves the right to assess late fees of 1.5% per month (18% annually) on all accounts over 30 days. We report all delinquent accounts to CoreLogic, formerly Compunet.

Authorized Name:

Title:

Date: