Confidential Application for Credit

Credit Application Company / Business Corporate Officer / Owner Detail Bank / Credit Reference Texas Land & Air References Disclaimer

Please fill in the following information. Those marked with an ( * ) must be filled in.

Company Details

Company Name:* DBA (if applicable):

Billing Address Address 1:* Address 2:* City:* State:* Zip:* Phone:* Fax: Shipping Address Address 1: Address 2: City: State: Zip: Phone: Fax:

Accounts Payable Contact Name:* Accounts Payable Phone:* Accounts Payable Fax:

Company / Business Information

Company / Business Type

Division Subsidary Branch Wholly Owned

Certifications:

CTPAT Designation: IAC Designation: Other Security Protocol:

Parent Company Details

Name:* Address 1:* Address 2: City:* State:* Zip:* Federal Tax Number: State Tax Number: Dun & Bradstreet ID: Type of Business: Type of Industry: Date Incorporated: State Incorporated:

Corporate Officer / Owner Detail

Owner / Officer #1 Name: Title: Home Address: Address 2: City: State: Zip: Phone: Officer #2 Name: Title: Home Address: Address 2: City: State: Zip: Phone: Owner / Officer #3 Name: Title: Home Address: Address 2: City: State: Zip: Phone:

Bank / credit References

Principal Bank Name:* Address 1:* Address 2: City:* State:* Zip:* Phone: Fax: Representative: Account Number: Account Type:     Credit Reference #1 Name: Address 1: Address 2: City: State: Zip: Phone: Fax: Contact Person: Credit Line $ Credit Reference #2 Name: Address 1: Address 2: City: State: Zip: Phone: Fax: Contact Person: Credit Line $ Credit Reference #3 Name: Address 1: Address 2: City: State: Zip: Phone: Fax: Contact Person: Credit Line $ Credit Reference #4 Name: Address 1: Address 2: City: State: Zip: Phone: Fax: Contact Person: Credit Line $

References with Texas Land & Air

Have you had an account with Texas Land & air before? Yes

If so, when?

Do you have a Texas Land & air representative? Yes

If so, name?

If not, would you like us to assign you one? Yes

Expected monthly freight charges: $

Disclaimer

Applicant certifies that the information above and all information accompanying this application is true and correct. Applicant authorizes Texas Land & Air to solicit and obtain credit information from the references above and from any other source. Applicant authorizes the references above and all other credit sources to disclose credit information to Texas Land & Air. Texas Land & Air will not disclose credit information about the applicant to any other person without applicant's prior written approval. Applicant agrees to pay all charges in accordance with applicable tariffs and/or terms, which will be provided or explained by applicant's Customer Service Representative upon request.