Automatic Payment Account Application

AUTOMATIC PAYMENT ACCOUNT APPLICATION

You are applying for an Automatic Payment Account with RTD Logistics

Organization's Legal Name*

D/B/A

Account Owner - First Name*

Account Owner - Last Name*

Account owner- Contact Phone Number*

Account Owner - Contact Email*

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How did you hear about us?*

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Account Billing Information

Do you require references for your orders and invoicing needs? (To help sort your bill, you can have references assigned to each order. The invoice will be subtotaled accordingly)*

Account Billing - Street Address*

Account Billing - Room/Apt/Suite

Account Billing - City*

Account Billing - State*

Account Billing - Zip Code*

Account Billing - Phone Number*

Account Billing - Primary Contact First Name*

Account Billing - Primary Contact Last Name*

Account Billing - Primary Contact Title*

Account Billing - Primary Contact Email*

BILLING TERMS AND CONDITIONS

THIS IS AN AGREEMENT THAT ESTABLISHES YOUR RTD CLIENT ACCOUNT WITH RTD Logistics AND THE TERMS AND CONDITIONS OF YOUR ACCOUNT: By requesting and permitting us to provide delivery services to you, you confirm acceptance of the terms and conditions of this Agreement. You are responsible for all amounts owed on this account, whether charged by you, a person whom you permit to use your account to order services from us, or any other person using your account with actual, implied or apparent authority.*

Agree

RTD RECURRING BILLING CONSENT FORM: I, the undersigned, consent and permit RTD LOGISTICS, LLC, dba Skycom Courier, to charge my credit card account specified above, as updated regularly ("Card Account"), any amounts due for services provided to me by RTD Logistics during the application billing cycles, unless and until RTD Logistics has received notification in writing from me that I have withdrawn such consent and permission. By way of this consent form, the undersigned agrees that RTD Logistics may be advised by credit card company of any changes to the status of the Card Account, including updated account number and expiration date information, to ensure my uninterrupted service by RTD Logistics, Skycom Courier.*

Agree

RTD PAYMENT TERMS: Unless other terms are arranged, payment is due within 15 days of the billing date. If this account becomes Overdue, RTD Logistics reserves the right to suspend service, without notice, until paid and overdue balances are paid. You agree to pay all costs of collection, including reasonable attorneys' fees, incurred to collect unpaid and overdue balances.*

Agree

INSURANCE: All deliveries are insured for $100.00. If you would like to declare a greater value on a shipment, the value must be declared and insurance must be purchased prior to the time of shipment.*

Agree

ELECTRONIC SIGNATURE AGREEMENT: By checking the "I Accept" checkbox below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By checking the "I Accept" checkbox below using any device, means or action, you consent to the legally binding terms and conditions of this agreement.*

I Accept

Printed Name and Electronic Signature*

Signee's Title*

Today's Date 00/00/0000*

Please verify your request*

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