New Customer Application

Please complete the application below:

Personal Information
Name
E-Mail
Company Name
Firm's Legal Name
Trade Name
Address
City
State
Zip Code
Country
Phone
Fax
Billing Contact
Faderal Tax ID No
Incorporated in State of
Date Business Started
DUN and Bradstreet Number
IATA Number

Bank References
Name
Account Number
Length of Relationship
Officer to Contact

Trade References
Firm Name
Account Number
Phone Number
Contact
High Balance
Present Balance
Length of Relationship
Terms
Confirmed By
Date

	I/We certify the information shown on this application to be correct. I/We authorize Mercury Air Group, Inc., and its subsidiaries and/or affiliates to investigate, now and from time to time as may be advisable by reported changes in financial condition, the references herein and/or other data obtained from me/us, or from other sources pertaining to my/our credit worthiness and financial responsibility. In addition, I/We agree to provide current financial information as Mercury Air Group may request of us from time to time to maintain this credit account in good standing.

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Title
Firm


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