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Credit Application
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Required Information
Company Name
*
Service Type
*
General Cargo
Hazmat
Bonded
Refrigerated
Physical Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Billing Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Business
Brokerage
Carrier
Freight Forwarder
Please provide your MC# or FF#
Maximum Load Value
*
< $50,000
$51,000-$100,000
$100,000-$250,000
$250,000-$500,000
$500,000+
Type of Freight
*
Imports / Exports
Dry Van
Flat Bed
Estimated Loads Per Month
Email for Invoicing
*
Company Classification
Year Business Started
*
DUNS Number
EIN
*
Company Type
*
Sole Prorietor
Limited Liability Company
Incorporation
Co-op
Limited Partnership
Stock Symbol
Accounts Payable Information
Accounts Payable Contact
*
First
Last
Accounts Payable Phone
*
Email
*
Will we invoice a third party payment processor?
*
Yes
No
Will we invoice other locations?
*
Yes
No
I.e Chicago office, New york office, Houston office.
Invoicing Requirements
Please select what is required when invoicing
*
Rate Confirmation Sheet
Purchase Order / Work Order
Transportation Order Sheet
TIR’s
Signed Accessorial Sheet / Form
Signed Proof of Delivery / Signed Bill of Lading
Do you have the ability to pay via ACH/Wire?
*
Yes
No
Do you have any additional Billing requirements?
Bank Reference
Bank Name
*
Bank Representative
*
First
Last
Phone
*
Email
*
Business Name Associated With This Account
*
Checking Account Number
*
Credit References - Minimum of 2 References
Credit Reference #1
Company Name
*
Contact Name
*
First
Last
Contact Phone
Contact Email
*
Credit Reference #2
Company Name
*
Contact Name
*
First
Last
Contact Phone
Contact Email
*
Credit Reference #3
Company Name
Contact Name
First
Last
Contact Phone
Contact Email
Bank Reference
General Terms And Conditions
I Accept The Terms And Conditions Contained In this Agreement
*
ACCEPT
Credit will be extended on the condition that customer agrees to make payment in accordance with the terms of the invoice. Customer will not delay or withhold payment due to the alleged errors in billing or because of any other dispute customer may have with JDSB Trucking or its affiliates or subsidiaries. Failure to make timely payments to JDSB Trucking or its affiliates or subsidiaries may result in cancellation of any credit extended. Any account that warrants collection action will be responsible for all associated collection fees including but, not limited to, attorney’s fees, court costs, collection agency fees and interest at the rate of two percent (2%) per month. Customer hereby acknowledges that it is applying for credit with a company whose principal place of business is located in Illinois. Customer agrees that it is availing itself to the jurisdiction and laws of Illinois with respect to this credit application and any claim involving or relating to the extension of credit and payment of bills hereunder. Customer agrees to submit to the jurisdiction of Illinois with any suit related thereto. Customer waives any argument or claim that Illinois lack jurisdiction over Customer and agrees to personal and subject matter jurisdiction in Illinois. Customer agrees to JDSB Trucking's attorney fees and costs related to any contest to jurisdiction in Illinois. Customer agrees to terms and conditions of JDSB Trucking Rules Tariff JDSG-100 as presented on www.jdsbtrucking.com. By checking accept, you are agreeing to these terms and conditions and are acklowging that you have read and understand Rules Tariff JDSG-100
Name
*
First
Last
Position
*
Signature
*
Clear Signature
Date
*
Email
*
Please Upload W9, Bond, Authority, or any other documents.
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