On-Line Credit Application

If you would rather print out and mail in your credit application, please click HERE.

Remember to also print, fill out and include your W-9 Form.

Please mail all forms to:

Champagne Logistics
7350 South Kyrene Road
Suite 108
Tempe, AZ  85283

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Company Information

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* Organization Type
  • Corporation
  • Partnership
  • Limited Partnership
  • Proprietorship
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Billing Information

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Business Information

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Please list all of your business names
and addresses that will be shipping.


Trade Reference 1

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Trade Reference 2

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Banking Institution

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Transportation Provider

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Credit Terms & Conditions

The above information is for the purpose of obtaining credit and is warranted to be true. I/We hereby authorize the firm to whom this application is made to investigate the references listed pertaining to my/our credit and financial responsibility. A copy of this document shall be as the original.

On behalf of our company, I certify that we agree to pay all invoices within 30 days from our invoice date. Further we certify that we are familiar with and agree to abide by the DOT/Surface Transportation Board rules and regulations pertaining to the payment of transportation and other tariff charges. If carrier is forced to utilized outside collection source, all applicable discounts and allowances will be revoked resulting in collection of gross charges.

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I agree that the above authorized name in printed form constitutes my signature in electronic format.

 

Shipment Tracking

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