Your photo here
Print
and Mail or Fax this Form
$150 (US) for 3 full months, pre-paid orders $250. for 6 months,
$500. for 1 year.
Master Card / Visa, Company Check by fax. Photo copy your check and
fax to
561-451-4243 Made payable toCrown Eagle, Inc.
Amount of: $150 for 3 months: __ $250 for
6 months: __ $500 for 1 year: __
Credit Card
information
(Please
Note: There is a 5% processing fee for all credit card
information)
Card Name: .........Master Card ___ Visa ___
Account #: ________________________________________ Expiration Date ________
Cardholder Name: (print name) ____________________________
Signature:____________________________
Please Note: Your order will be processed by Les Schwartz, Inc. Their name will appear onyour credit card billing statement for yhe amount of this purchase. ($25 fee will be charged for re-processing of charge backs)
Your Name: _______________________________
Address: _____________________________ City: ___________ State: ___ Zip: __________
Business Address: ________________________ City: _____________ State: ___ Zip: __________
Phone: (Home) _____________________ (Business) _____________________
Fax: __________________ E-mail: ___________________ Other: __________________
Company Name: ____________________________________
CDL Class: _____ Endorsement (s): ____________________________________
Please Fax Copies of your U.S.D.O.T. Certificate, Motor Carriers Authority and Insurance.
Truck: Year: ____ Make: ____________ Model: ______ Trailer : Year ___ Make___________
Tractor: Year: _____ Make: ____________ Model: _______ Trailer: Year ____ Make:________
Load Capabilities: Maximum: _______________
Desired Areas of Operation: All 48 states: __ North __ South __ East __ West _
Eastern seaboard: __ Southeast: __ Mid-Atlantic: __ New England __
Midwest __ South Central __ North Central __ Southwest __ Northwest __
Central Mountain __ West Coast __
Additional Information: ___________________________________________________________
________________________________________________________________________________
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