DIRECT BILLING ACCOUNT APPLICATION FORM
Please type or print clearly
I.BUSINESS CONTACT INFORMATION:
Company Name
Type of Business
Company Address
 
City
State / Province
ZIP / Postal Code
Country
Phone
Facsimile
Main Contact Name
Title
Work Phone
Cell Phone
Email
Facsimile
II. BILLING CONTACT INFORMATION:
Billing Address
City
State / Province
ZIP / Postal Code
Country
Phone
Facsimile
Billing Contact Name
Work Phone
Cell Phone
Email
Facsimile
 
III. CREDIT INFORMATION:
Dun & Bradstreet
Dun & Bradstreet Number
Bank Reference
Bank Name
Contact Name
Tittle
Address
City
State / Province
ZIP / Postal Code
Country
Phone
Facsimile
Email
Account Number
Credit Card(Required)
Credit Card Type
AMEX MC VISA DISCOVER DINNERS CLUB
Account Number:
Expiration Date:
Account Holder Name:
Account Holder Signature:
Date :
 
Trade References
Note: Landlords, utilities, and other ground transportation companies are not accepted
Company Name
Contact Name
Address
City
State / Province
ZIP / Postal Code
Country
Phone
Facsimile
Email
Account Number
Company Name
Contact Name
Address
City
State / Province
ZIP / Postal Code
Country
Phone
Facsimile
Email
Account Number
Company Name
Contact Name
Address
City
State / Province
ZIP / Postal Code
Country
Phone
Facsimile
Email
Account Number
 
IV. PAYMENT OPTIONS:
BostonAsapCoach offers the following payment options
  1. Payments can be mailed to our P.O.Box address listed below
    BostonAsapCoach
    P.O.Box 590686
    Newton Center, MA 02459
    United States

  2. Payments can be applied to a single credit card in one lump sum at the end of the each month. Please send letter of authorization on your company's letterhead to BostonAsapCoach , P.O.Box 590686, Newton Center, MA 02459, United States. Attn: Accounts Department, or fax it to 617 500 9945
V. TERMS OF PAYMENT
BostonAsapCoach invoices are due upon receipt. A late fee of 2% per month will be added to all invoices that have not paid more than thirty (30) days after the receiving of receipt. In case of errors or questions with regards to your invoice, BostonAsapCoach must hear from you within 3 weeks of receiving the invoice in writing, on which a specific issue has appeared You may withhold the payment on the amount in question while we are investigating the charge(s). You remain obliged to pay any part of the invoice that is not in question including any late fee.

In the event of your account is outstanding in excess of sixty (60) days, it will be considered as a delinquent or in default. BostonAsapCoach reserves the right to place accounts that are determined to be delinquent or in default on credit hold and charge the credit card on file for the balance owed, in cluding any late fee. Additionally if a credit card is inactive, expired, or for other reason is not charged the outstanding balance owed, BostonAsapCoach reserves the right to initiate a collection proceedings on such accounts. BostonAsapCoach will collect any and all attorney's fees, collection expenses, and court costs incurred by BostonAsapCoach in its effort to collect the outstanding balance owed. Additionally, BostonAsapCoach reserves the right to convert all overdue accounts to a credit card only status for services provided in the future.

By signing below you agree to the terms of this application, and consent to BostonAsapCoach contacting the credit references listed herein. If the application is for a corporate account, the signature must be an officer or authorized representative who is legally able to the bind the company.
Name (Require)
Tittle
Signature (Require) :
Date :
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Please fill the form and add the signature by browsing the file and submit the form to send. In case, you do not have scanned signature, please fill the form and print it and Sign this form and then fax it to 617 500 9945 , or scan and Email to account_request@bostonasapcoach.com