Commercial Credit Application

Firm Name*

Parent Company, if Subsidiary*

Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address if Different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Fax Number

Please enter a valid phone number.

Email Address for Invoicing*

example@example.com

Purchasing Agent*

Check One*

CorporationPartnershipIndividual

How many years have you been in business?

If Corporation, Federal ID Number

If Individual, Social Security Number

Name of Owners/Officers/Members (List home address for partners or individual)*

Have You Filed for Bankruptcy in the Last 14 Years?*

YesNo

If You Filed for Bankruptcy, Give Us the Date

Date

Are There Any Judgments Against You?*

YesNo

Will You Purchase:*

GasolineDieselKeroseneLubricants

If Fuel or Lubes, Estimated Monthly Volume: *

Load Tax Exemption Here

Trade References #1: List Name, Address & Phone Number*

Trade References #2: List Name, Address & Phone Number*

Trade References #3: List Name, Address & Phone Number*

1. This application is submitted by the undersigned (“Applicant”) for the purpose of obtaining a credit account with Hutchens Rentz - Eden (“Hutchens”). Hutchens shall have the right at any time to assign this instrument to one of its subsidiaries or affiliates, in which event the name “Hutchens” as used in these Terms and Conditions and the Guaranty below shall be deemed to apply to such subsidiary or affiliate.

2. All representations and information provided by Applicant are accurate, complete and truthful.

3. The Applicant hereby authorizes any individual, firm, or corporation given as a credit reference to disclose to Hutchens, orally or in writing, any information which is pertinent to this application.

4. If the Applicant is a corporation, the undersigned represents and warrants that he is duly and property authorized to make application on behalf of said corporation and to obligate same for any credit extended as a result of this application, and further that the corporation will continue to be bound and obligated for any credit advanced until notice to the contrary is given in writing to Hutchens.

5. Credit extended by Hutchens to Applicant shall be due in full 30 days subsequent to the invoice date of each purchase unless otherwise stated on invoice or agreed in writing by the parties. A finance charge of 1.5% per month will be assessed on the balance subject to finance charges as determined on the last business day of the monthly billing cycle.

6. If this Agreement or the Account is referred for collection or Hutchens is forced to take other collection action, the Applicant agrees to pay collection charges, including all court costs, expenses and reasonable attorney’s fees, in addition to other sums owed.

7. Applicant further agrees that these Terms and Conditions shall inure to the benefit of Hutchens and its subsidiaries, affiliates, successors and assigns and shall bind the heirs, executors, personal representatives, administrators, assignees, purchasers and other successors of the Applicant. If any provision or part of these Terms and Conditions is in conflict with any applicable statute or rule of law, such provision, or part thereof, as the case may be, shall be deemed null and void to the extent that it may conflict therewith, but without invalidating the remaining provisions hereof or the remaining part of such provision. In consideration of Hutchens’ extension of credit, the Applicant hereby expressly waives any right of trial by jury in any proceeding arising out of, or relating to, this Agreement. The Applicant further consents to exclusive jurisdiction and venue for any such action in the State courts in Patrick County, Virginia.

Date*

Date

Company Name #1*

Owner, Office, Member Signature #1*

Printed Name #1*

Title #1*

Social Security Number #1*

Company Name #2

Owner, Office, Member Signature #2*

Printed Name #2*

Title #2*

Social Security Number #2*

FOR THE VALUE RECEIVED, the undersigned jointly and severally if more than one, does unconditionally guarantee payment of all sums now or hereafter owed by Applicant to Hutchens, including without limitation attorneys’ fees as specified in the Terms and Conditions set forth above, if Applicant defaults in its payment of any such indebtedness. It is understood that this Guaranty shall be a continuing and irrevocable guaranty of payment of said indebtedness of the Applicant and Hutchens shall not be obligated to notify the undersigned of the dates or amounts of any such credit. The undersigned Guarantor expressly waives notice of acceptance of this Guaranty, the benefit of all exemptions and homestead laws, all set-offs and counterclaims, all other notices to which the undersigned might otherwise be entitled, presentment, notice of default, notice of non-payment, and protest and consents to any extension of time of payment granted by Hutchens. The undersigned shall also pay all collection costs, expenses and court costs, including without limitation reasonable attorney’s fees incurred by Hutchens in collecting the indebtedness or enforcing this Guaranty. This Guaranty shall inure to the benefit of Hutchens and its subsidiaries, affiliates, successors and assigns and shall bind the heirs, executors, personal representatives, administrators, assignees, purchasers and other successors of the undersigned. If any provision or part of this Guaranty is in conflict with any applicable statute or rule of law, such provision, or part thereof, as the case may be, shall be deemed null and void to the extent that it may conflict therewith, but without invalidating the remaining provisions hereof or the remaining part of such provision. In consideration of Hutchens’ extension of credit to Applicant, the undersigned hereby expressly waives any right of trial by jury in any proceeding arising out of, or relating to, this Guaranty. The undersigned further consents to exclusive jurisdiction and venue for any such action in the State courts in Patrick County, Virginia.

Date*

Date

Signature*

Clear

Typed Name*

First NameLast Name

Signature

Clear

Typed Name

First NameLast Name

Commercial Credit Application

Trade References

Terms & Conditions of Credit

Read & Sign