Please complete and fax to (503)282-1416
MercuryPDX Account Information
Date					Account Number(office use only)
Business Information
Business Name
Street Address
City			State	Zip
Telephone #			Fax #			E-Mail Address
Billing Information (if different)
Attention to			Telephone #			Fax #
Business Name
Street Address
City			State	Zip		E-Mail Address
Name of Authorized Payment Person					Specific Instructions
Terms
All established businesses will receive immediate credit terms by faxing this form to (503)282-1416. All accounts are billed bi-monthly, and terms are net 10 days. Past due amounts over 30 days will be charged 1.8% monthly interest on any unpaid balance. Please call our office at (503)247-8484 if you need more information.
Signature						Date
Print Name						Title
Mercury Messenger
P.O. Box 2274 Portland OR 97208-2274