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Blue Goose Trucking Billing Application

* Required Field

Company Name: *
Company Address: *
Room/Floor #:
City: *
State: *
Zip: *
Phone: *
Fax #:
E-mail address: *
 

Accounts Payable Contact:
Accounts Payable Address:
Room/Floor/Suite #:
City:
State: *
Zip:

Phone:
Fax #:
E-mail address:
 
Type of Business: *
Years Established: *
How would you like to receive your invoices ? *




How would you like to receive proof of delivery ? *




          
What is your average monthly courier bills ? *

 

Business References

 

1. Company: *
Contact Name: *
Address: *
City: *
State: *
Phone: *
2. Company: *
Contact Name: *
Address: *
City: *
State: *
Phone: *
3. Company:
Contact Name:
Address:
City:
State: *
Phone:

 

Bank Reference

 

Bank Name: *
Acct # *
Branch Address: *
Branch City/State/Zip: *
Phone #:
Contact Person:

 

Credit Card Authorization

 

Please provide a credit card number to establish credit.

Invoices that remain open in excess of 35 days may be charged

 

Cardholder’s Name:
Address:
City:
State: *
Card Type
Card # Exp.

 

Please be advised that Blue Goose Trucking limits its liability to maximum of $2,000.00 per delivery unless otherwise negotiated in writing. In consideration for credit being extended by Blue Goose Trucking, I acknowledge and agree to the following: (1) Payment for all work performed by Blue Goose Trucking is personally, jointly, severally, and unconditionally guaranteed within 15 days of billing; (2) any charges outstanding after 35 days can be charged on the credit card indicated above; (3) any charges outstanding after 60 days from date of billing are subject to collection, and all collection or arbitration expenses, attorney fees, and court costs will be borne by the purchaser; (4) all claims, requests for adjustments, or notification of errors must be made within thirty days; or charges are considered accepted; (5) Blue Goose Trucking assumes no responsibility for the condition of the item being shipped; (6) this agreement shall apply to all current and future charges unless revocation is registered mail;(7) releases Blue Goose Trucking, its employees and or agents from liability and responsibility for the condition of the items throughout the receipt and delivery process (8) represents to Blue Goose Trucking. that the contents of the shipment is not hazardous or illegal in nature.(9) all work is subject to the Terms and Conditions above. My name below is confirmation that I have read and understand this agreement.

              Authorized Virtual Signature: *



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