CITY COURIER SYSTEMS  

CCS CUSTOMER ACCOUNT INFORMATION REQUEST

City Courier Systems would like you to fulfill your entire courier needs and help you to keep driving your business to success by offering you credit terms with a company account. After your completion of the application below, we will determine if an initial credit line can be established so that your courier needs can be met. To expedite your request, please fax or mail the application back at your earliest convenience. If additional credit reference information is required, your account representative will notify you.

Legal Name of Business: ____________________________________________________________

Phone #: ________________________________ Fax #: __________________________

Billing Address: ________________________________________________ Suite # _________

City: ________________________________________ State: __________ Zip: _______

Name of Contact: ___________________________ Other Assignee’s: ________________________

Are you a: Corporation_______ Sole Proprietor_________ Partnership______ Other_________

Type of business: ____________________________________________________________________

The undersigned certifies that the above information is true and correct and agrees to pay for all services rendered in compliance with the vendor. Unless otherwise agreed to in writing, said terms are that all services are to be paid upon completion for all delivery/courier services rendered. If qualified net 30 terms can be issued. Should default be made in payment when due, the balance plus 1% per month (12%APR) on all unpaid sums, together with the actual attorney’s fee and all costs as the seller may reasonably incur in the enforcement of the obligation, will be applied.  

Dated this _________________day of _______________2008

Print Name: ___________________________________________

Signature: _____________________________________________

City Courier Systems

6935 Aliante Pkwy

Suite 104-523

N. Las Vegas NV 89084

OFFICE: (702) 767-1558 FAX: (702) 487-5267

To Save Time You May Want to Fill Out This Form and FAX or Email it to our office.