Company Name:
Street Address:
City:
Zip:
Telephone No:
Fax No:
Billing Address:
Contact for Accounts Payable:
E-mail Address:
OWNERSHIPPROPRIETORSHIPPARTNERSHIPCORPORATION
Bank Name:
Address:
Account No:
Name on Credit Card:
Address where your bill is mailed:
CIRCLE TYPE OF CREDIT CARD: MASTER CARD, VISA OR AMERICAN EXPRESS:
Credit Card Number:
Expiration:
3 Digit Number for MC or Visa and 4 Digit number for AX:

I UNDERSTAND AND AGREE TO THE FOLLOWING TERMS:
THE ABOVE IS TRUE AND IS SUBMITTED FOR THE PURPOSE OF OPENING AN ACCOUNT WITH DYNAMIC DELIVERY, INC. THIS WILL AUTHORIZE DYNAMIC DELIVERY TO VERIFY THE ABOVE INFORMATION. DYNAMIC DELIVERY, INC. WILL NOT BE RESPONSIBLE FOR THE COST OF ANY ITEM NOT DECLARED AT THE TIME THE ORDER IS PLACED. OUR MAXIMUM LIABILITY IS $25.00 PER DELIVERY. YOUR ACCOUNT WILL BE BILLED TWICE A MONTH AND PAYMENT IS DUE WITHIN 10 DAYS OF THE BILLING DATE. APPLICANT AGREES TO PAY ALL MONIES DUE WITHIN TERMS GRANTED. DYNAMIC RESERVES THE RIGHT TO CHARGE YOUR CREDIT CARD FOR PAST DUE BALANCES NOT PAID WITHIN OUR CREDIT TERMS, ALONG WITH AGREEING TO PAY FOR ANY COLLECTION EXPENSES INCLUDING ADMINISTRATIVE COST , COURT COST, ATTORNEY OR ARBITRATE FEE’S DUE TO NON PAYMENT. NO TIME GUARANTEE’S AND NO SIGNATURE GUARANTEE ON YOUR DELIVERY.

Name & Title:
Signature:
Date:
Brian Wisz Dynamic Delivery, Inc 818.598.8700 celebrating 17 years of service www.Dynamicdeliveryinc.com

Account Application