Application Name:
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
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: