Form

KGM EXPRESS, INC
17935 Grant Rd. Cypress, Texas 77429
Office: 713-856-5900 Fax: 713-596-5914

APPLICATION FOR CREDIT
PLEASE ANSWER ALL QUESTIONS COMPLETELY

Date *

- Month - Day Year

Phone Number *

- Area Code Phone Number

Fax Number *

- Area Code Fax Number

Legal Name of Business *

Business Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Billing Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

AFFILIATED COMPANIES

Type of Business *

Individual Partnership Corporation

If not a corporation, Name of responsible party

If not a corporation, Social Security Number

Brief description of business *

Name of Bank *

Bank Address *

Is your company listed with Dun and Bradstreet *

Yes No

Trade References (3)

Payable Supervisor *

Telephone: *

- Area Code Phone Number

Purchase order required? *

Yes No

Job number required? *

Yes No

We certify all the information on this form is correct; and that we understand you credit terms ARE UPON RECEIPT, unless prior arrangements have been made. We agree to these payments in consideration of extended credit. This application warrants that he is fully authorized to enter into this credit agreement by and on behalf of the firm.

Full name *

Entering your full name equates to your signature.

Title *

Date *

- Month - Day Year