Credit Application

Credit Application
Name (First, M.I., Last)*
Birth Date*

MonthDayYear
Date
Social Security #*
Phone Number*
Spouse’s Name First, M.I., Last*
Street Address*
City*
State*
Zip Code*
County*
Email Address*
example@example.com
Would you like invoices emailed to you?*

YesNo
Place of Employment:*
Is your house Owned or Leased?*
Name of landlord
Is your tank Owned or Leased?*
What services are you looking for?
Credit References:
Bank Name*
City*
Account Number*
Contact Name*
Phone Number*
I certify that the above information is true and correct. I authorize the above parties contacted to re- lease any information to Wessels Oil Company.
Signature*
Date*

MonthDayYear
Date
Spouse's Signature*
Date*

MonthDayYear
Date
Pocahontas State Bank

233 N Main, P.O. Box 130

Pocahontas, IA 50574
Tel: 712-359-7712 Email: wessels@wesselsoil.com

Fax: 712-359-2307 www.wesselsoil.com

421 Railroad Avenue Palmer, IA
Should be Empty: