Northam Account Setup Form – NorthamLogistics

Primary Business Information

Exact Legal Business Name *

Parent Company

Doing Business As

Fed ID #

Year Established *

Phone Number *

Fax Number

Cell Number

Email *

Mailing Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Physical Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Incorporated in what jurisdiction?

Do you have other accounts under the name listed above or under any other name? *

No
Yes

If so what name?

What State / Province?

Have you ever filed for bankruptcy? *

No
Yes

Account Payable Contact

Phone #

Company Bank

Branch

Acct #

Do You Require Purchase Orders? *

No
Yes

Ownership

Type of Business

Owner/Officer #1 *

First

Last

Owner/Officer #1 Title *

Owner/Officer #2

First

Last

Owner/Officer #2 Title

Owner/Officer #3

First

Last

Owner/Officer #3 Title

Trade References

Reference #1

Business Name

Full Name

Phone Number

Reference #2

Business Name

Full Name

Phone Number

Reference #3

Business Name

Full Name

Phone Number

I certify that all information on this form is correct. I agree to pay all debts incurred within thirty (30) days of receipt of the invoice. This agreement constitutes the entire agreement between the creditor and the applicant. It can be amended only in writing. Statements outstanding for thirty (30) days will accrue an interest charge of 18% per annum (1.5% per month). Creditor shall be entitled to reasonable collection and attorney fees as determined by a court of law.

Customer's Name and Title *

Phone Number *

Email *

Date *