Credit Application

Credit apps take up to two business days to process

Tax ID Number(Required)

Bill To Company Name(Required)

Company Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Company Phone # For Accounts Payable(Required)

Billing Email Address(Required)

Primary Contact Name For Billing(Required)

First Last

Alternate Contact Name For Billing

First Last

Alternate Contact Email Address

I authorize Simple Ship to verify the information provided on this form as to my credit worthiness.

Signature Of Applicant(Required)

Date(Required)

Signature of co-applicant, if for joint account

Date

35451

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