Credit Application

Credit Application
Ship To Business Info
Business Name
Business Name
(DBA) Trade Name
DBA Trade Name
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email
example@example.com

Bill To Business Info
Business Name
Business Name
(DBA) Trade Name
DBA Trade Name
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email
example@example.com

Business Facts
Business Type

ProprietorshipPartnershipCorporationOther
How Many Years Have You Been in Business Under this Business Name?
Federal ID #
Tax Exempt

Yes (If yes, please attach Tax Exemption Certificate below)No
Tax Exempt Number
Tax Exempt Certificate Upload

Browse Files

Cancelof
Is this business a subsidiary / affiliate of any other entity?

YesNo
If Yes, identify the entity(ies).

Personal Info on Primary Officer(s)
Primary Officer 1 Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Mobile Phone Number

Area CodePhone Number
Primary Officer 2 Name

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Mobile Phone Number

Area CodePhone Number

If you are a Proprietorship please fill in the following:
Social Security Number
Driver's License Number

Accounts Receivable Information
Contact Person

First NameLast Name
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Email
example@example.com
Are Purchase Order Numbers Required?

YesNo

Banking References
Bank Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Officer

First NameLast Name
Checking Account Number

Credit References
Credit Reference 1- Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Credit Reference 2- Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Credit Reference 3- Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
Credit Reference 4- Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number

Who is your Present Petroleum Supplier?
Which of the following are you applying for? (Check all that apply)

Oil AccountCFN Fueling Card*Bulk Fuel Delivery Account*
* Account REQUIRES electronic payment.
Please Specify Amount of Credit Requested:
Are You Interested in Electronic Payment Option?

YesNo

Individual Guarantor 1 Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
Date
Social Security Number
Individual Personal Guaranty Signature 1

Clear

Individual Guarantor 2 Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
Date
Social Security Number
Individual Personal Guaranty Signature 2

Clear

Terms Agreement
Name

First NameLast Name
Title
Date

MonthDayYear
Date
Owner or Officer Signature

Clear
Should be Empty: