Credit Request

Please complete all sections. Click the Submit button to continue.

 
MASON AND DIXON LINES, INC. - CREDIT REQUEST
Terminal
 Line of Credit Requested
Is this for a Broker (Y/N)

Email Address (Optional)


LOAD INFORMATION
Load Date
 Load Revenue
Number of Loads
 Per   
Commodity
From:
Company  (Optional)

Location 


 To:
Company (Optional)


Location

CREDIT CHECK REQUESTED FOR
Business Name
Phone *

 Fax

Broker MC #
 Duns #
Address Line 1
 Address Line 2
City State
Zip
Contact
 Federal Tax ID Number
Years in Business
 Has the firm or any of its Principals ever filed bankruptcy?
EDI Capable?
 EFT Capable? 
Auto Pay? 
Required Customer Documentation for Freight Payment



Comments (Optional)

REFERENCES
References Available if Requested?
 
Carrier References (Optional)
Name 

Address
Phone Number
Name 
Address
 Phone Number
Name 
Address
 Phone Number
Bank Reference (Optional)
Name 

Address
Phone Number
Account Number 
Contact