Get Started With deliverLA
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Company Name
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Sole Ownership
Partnership
Corporation
LLC
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Type of Business:
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Year Established
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Name of Owner/CEO
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Company Contact Info:
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Address
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Suite #
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City
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State
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Zip Code
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Phone Number
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Fax Number
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Website
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Your info (if different than owner)
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Your Name
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Your Tiltle
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Email
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How did you hear about us?
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Published Ad
Received
Mailer
Search
Engine
Car/Van
Advertising
Referred
by a friend/company
Approached
by a sales staff
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If referral, please name person/company
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If published ad, please name publication
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If search engine, please name site
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Your current delivery status
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What is the average number of your deliveries?
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Per?
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Day
Week
Month
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What is your monthly delivery expense?
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Please tell us if you need any special daily pickups or delivery arrangements:
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Previous Delivery Service:
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Reason for Switching?
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Credit & Trade References:
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Bank Name:
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Branch:
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Do you wish to pay your bills by
Credit Card?
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Yes
No
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If yes, cc type:
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American
Express
Discover
Master Card
Visa
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Card #
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Exp
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CW/CVS code
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Billing Zip
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Trade Reference 1
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Phone Number for Trade Reference 1
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Trade Reference 2
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Phone Number for Trade Reference 2
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Complete Account Request
Thank you for choosing deliverLA for your time sensitive deliveries. After reviewing your information, we may extend credit and invoice you for services
rendered. Please be advised
that our invoices are due upon receipt and we ask for prompt payment off all invoices. In the event that you are delinquent on payments, interest and late penalties may apply. In
the event of a dispute or loss, you must make a claim within three business days of such event. In case of a claim against us, you may not withhold payment on services already
rendered. Our rates are subject to change based on industry trends, cost of doing business, your volume and payment habits. Rate changes may occur without advance notice. This paragraph is
a part of our agreement and condition of us providing service.
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Do you agree with the terms and conditions?
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Yes, I
agree.
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Initial
*
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Date
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MM
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DD
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YYYY
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Image Verification
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