Get Started With deliverLA
Company Name *
 Sole Ownership 
 Partnership 
 Corporation 
 LLC 
Type of Business:
Year Established *
Name of Owner/CEO *

First

Last

Company Contact Info:
Address *
Suite #
City *
State *
Zip Code *
Phone Number *

###
-
###
-
####
Fax Number

###
-
###
-
####
Website

Your info (if different than owner)
Your Name

First

Last
Your Tiltle
Email *

How did you hear about us?
 Published Ad 
 Received Mailer 
 Search Engine 
 Car/Van Advertising 
 Referred by a friend/company 
 Approached by a sales staff 
If referral, please name person/company
If published ad, please name publication
If search engine, please name site

Your current delivery status
What is the average number of your deliveries? *
Per? *
 Day 
 Week 
 Month 
What is your monthly delivery expense?
Please tell us if you need any special daily pickups or delivery arrangements:
Previous Delivery Service:
Reason for Switching?

Credit & Trade References:

Bank Name: *
Branch: *
Do you wish to pay your bills by Credit Card? *
 Yes 
 No 
If yes, cc type:
 American Express 
 Discover 
 Master Card 
 Visa 
Card #
Exp
CW/CVS code
Billing Zip
Trade Reference 1
Phone Number for Trade Reference 1

###
-
###
-
####
Trade Reference 2
Phone Number for Trade Reference 2

###
-
###
-
####

Complete Account Request

Thank you for choosing deliverLA for your time sensitive deliveries. After reviewing your information, we may extend credit and invoice you for services rendered. Please be advised that our invoices are due upon receipt and we ask for prompt payment off all invoices. In the event that you are delinquent on payments, interest and late penalties may apply. In the event of a dispute or loss, you must make a claim within three business days of such event. In case of a claim against us, you may not withhold payment on services already rendered. Our rates are subject to change based on industry trends, cost of doing business, your volume and payment habits. Rate changes may occur without advance notice. This paragraph is a part of our agreement and condition of us providing service.

Do you agree with the terms and conditions? *
 Yes, I agree. 
Initial *
Date *

MM
/
DD
/
YYYY
Image Verification
captcha
Please enter the text from the image:
[Refresh Image] [What's This?]