Credit Application

robust

Name of Company

Address

City

Province / State

Postal / Zip Code

Phone No

Nature of Business

Years in Business

Annual Sales

Dun and Bradstreet No.

Credit Amount Requested

Jurisdiction of Incorporation

Please Check One of the Following:

Partnership

Individual/SoleProprietorship

Corporation

Ordering Information

Contact Name

Contact E-Mail Address

Contact Phone No.

A/P Contact Name

A/P Contact E-Mail Address

A/P Contact Phone No.

Billing Address (if different)

Address

City

Province /State

Postal / Zip Code

Shipping Address (if different)

Address

City

Province /State

Postal / Zip Code

Bank Information

Name of Institution

Branch

Contact Name

Phone No

Account No.

Name of Institution

Branch

Contact Name

Phone No

Account No.

Trade References

Company Name

City

Province /State

Postal /Zip Code

E-Mail Address

Phone No.

Fax No.

Company Name

City

Province /State

Postal /Zip Code

E-Mail Address

Phone No.

Fax No.

Company Name

City

Province /State

Postal /Zip Code

E-Mail Address

Phone No.

Fax No.

The undersigned hereby declares that all the information provided herein and on any accompanying applications or statements is to the best of my knowledge, true, complete and correct. It is understood that the information provided will be fully researched. I hereby authorize and release all banks, persons and companies listed on this application to furnish and authorize the checking of credit to Robust Transport Services Ltd. The undersigned certifies that he/she is empowered to grant the release and agree to the information provided

Name and Title:

Date

Signature