[*]required info

Courier Service Billing Information Client Code* Billing Reference* Company Name* Telephone* Courier Pick Up Information Pick Up From* Street Address* City* State* Zip Code* Courier Delivery Information Deliver To* Street Address* City* State* Zip Code* Instructions for Messenger Who do we see for pick up ?* If we are delivering to a residence is it OK to leave the package? YES NO Round Trip YES NO Type of Messenger Service (requests for non stops must be called in) Regular Call When Delivered YES NO Other Information, Including Request Delivery Time*   I understand and agree to the following terms: The above is true and submitted for the purpose of opening an account. This account will be billed twice a month and payment is due on receit.   Your Name & Title*  Owner's Name Email* Company Website