Date:     
Company/Firm  
Application Name: 		    
Address:     
City:    State:  Zip: 
Mailing Address:     
Type of Business:  Date Established: 
Phone:  Fax: 
Date acquired by present management:     
Business Property:   Leased:  Owned:
Business:  Corporation:  Proprietorship:  Other: 
Principals (List Officers and /or Partners):      
Position:  Phone: 
Position:  Phone: 
Position:  Phone: 
         
Current Credit Accounts Complete Address
1.  1. 
2.  2. 
3.  3. 
4.  4. 
5.  5. 
6.  6. 
         
Name of Bank Account # Complete Address Phone
1. 
2. 
3. 
         
The undersigning person for himself (and on behalf of the corporation, partnership, or other legal entity whose name is written above his signature) agrees with Miami Transfer/Florida Rigging & Crane that a security interest in all goods and services sold by Miami Transfer/Florida Rigging & Crane is retained by it and agrees to pay interest of 1.5% per month on all past due accounts, together with all reasonable costs of collection, including attorney's fees. (The undersigning person hereby authorizes all listed Creditors & Banks to release to Miami Transfer/Florida Rigging & Crane such credit information as may be requested by them. A photo-copy of this application shall be deemed authorization to release this information.)
         
Authorized Signature of Applicant and Title: