Credit Application / Address Change Form (Please Print Clearly)

Name of Business:
/ Name of Person Providing Information:
Billing Address (No P.O Boxes) / Federal Tax I.D. Number:
City: State: / D-U-N-S (D&B) Number:
ZIP Code: Phone Number : / Email Address:

Bank References

Institution Name:
Address:
Phone:

Trade References

Company Name: / Company Name:
Contact Name: / Contact Name:
Address: / Address:
Phone: / Phone:

PRIVACY ACT NOTICE

“49U.S.C. 114 authorizes the collection of this information. The information you provide will be used to qualify you or verify your status as a possible “known shipper.” Providing this information is voluntary; however, failure to provide the information will prevent you from qualifying as a “known shipper.” This information will be disclosed toTSA personnel and contractors or other agents, including indirect air carriers (IAC), in the maintenance and operation of the known shipper program.TSA may share the information with aircraft operators, foreign air carriers, IACs, law enforcement agencies, and others in accordance with the Privacy Act, 5U.S.C. Section 552a. For additional details, see the system of records notice for Transportation Security Threat Assessment System (DHS/TSA 002) published in the Federal Register.

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions, companies and individuals listed in this credit application to release necessary information to the company for which credit is being applied for in order to verify the information contained herein.

______

Signature Date

Please email completed & signed application to or fax to 1-718-228-7681

Credit Application / Address Change Form (Please Print Clearly)