QUALITY OIL CREDIT APPLICATION AND AGREEMENT FORM

CREDIT APPLICATION AND AGREEMENT FORM
This is the Quality Oil Credit Application and Agreement Form. Please fill out all required fields to this online form to the best of your ability.

You can save your progress and return to complete the form at a later point. To do so, click the save button on the form below.Once you click save, you will have the option to: 1. create a Jotform account to later complete the form or 2. get a link sent to you via email.

If you have any questions or need your unique URL to complete this form, please contact dealers@qocnc.com. To download a paper version of this application to submit via email, click here.

GENERAL COMPANY INFORMATION
Name

First NameLast Name
Email*
example@example.com
Company Name *
State*
DBA*
Company Type*
State Resale Number*
Company Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Are you inside city limits?
County*
Type of Business*
Years in Business*
If the business has changed names in less than one year, please list your previous business name and address:

CONTACT INFORMATION
Accounts Payable Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Fax

Area CodePhone Number
E-mail*
Purchasing Contact (If different from Accounts Payable Contact)

First NameLast Name
Phone Number

Area CodePhone Number
Fax

Area CodePhone Number
E-mail
Has your company ever filed for bankruptcy?*
What Chapter
Date of Filing
Contractors License Number
Type of License

OFFICERS OF THE COMPANY AND TITLES
Officer of the Company Name*

First NameLast Name
Title
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Officer of the Company Name

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Officer of the Company Name

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

BANK ACCOUNTS AND CONTACTS
Bank*
City*
State*
Phone Number*

Area CodePhone Number
Contact name*
Bank
City
State
Phone Number

Area CodePhone Number
Contact Name
Bank
City
State
Phone Number

Area CodePhone Number
Contact Name

LOCAL BUSINESS CREDIT REFERENCES
Business Credit Reference 1 Name*

First NameLast Name
City*
State*
Phone Number*

Area CodePhone Number
Fax

Area CodePhone Number
Business Credit Reference 2 Name*

First NameLast Name
City*
State*
Phone Number*

Area CodePhone Number
Fax

Area CodePhone Number
Business Credit Reference 3 Name*

First NameLast Name
City*
State*
Phone Number*

Area CodePhone Number
Fax

Area CodePhone Number
Optional Business Credit Reference Name

First NameLast Name
City
State
Phone Number

Area CodePhone Number
Fax

Area CodePhone Number
Current Petroleum Supplier
Monthly Volume
Does this Company own real property?*
Property Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Address 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ASSETS & LIABITILIES
Please add information about the assets and liabilities below. To calculate net worth at the end of the section, subtract liabilities from assets. Supporting financial documentation may be requested.
Assets (please enter numeric values without $ sign).
Cashing (Savings) Account*
Certificates of Deposit*
Cashing (Checking) Account*
Notes (Contracts) Owed to You*
Certificates of Deposit*
Treasury Bills*
Savings Certificates*
Life Insurance (Cash Value)*
Precious Metals*
Securities (Stocks or Bonds)*
Money Market Funds*
Individual Retirement Plans (IRA)*
Real Estate (Market Value)*
Vehicles (Market Value)*
Tools and Equipment*
Other Assets*
Total Assets
Liabilities (please enter numeric values without $ sign).
Credit Card Obligation*
Home Mortgage*
Other Mortgages*
Auto Loans*
Personal Loans*
Personal Guarantees*
Educational Loans*
Business Loan Obligations*
Taxes Owed*
Other Debts*
Total Liabilities
Net worth (calculated from Total Assets - Total Liabilities)

TANK INFORMATION AND UST PERMIT

Tank Sizes (in Gallons)*

	Above Ground	Under Ground
Regular
Plus
Premium
K-1
Diesel (on-road)
Diesel (off-road)
Other
Other
Other

Are all tanks properly labeled with approved decals?*
Are tanks and drops clearly labeled to identify product?*
UST Permit - Required for Underground Tanks

Quality Oil Company must have a copy of a valid UST permit on file at all times or delivery cannot be made.
Facility ID#
Certificate #
Expiration Date
Please include a copy of your UST permit with this application or email this document to dealers@qocnc.com. *

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COMMERCIAL DEALER DISCLOSURE AUTHORIZATION AND RELEASE

In connection with my application to become a commercial reseller of petroleum products supplied by Quality Oil Company, LLC (“Quality Oil”), I hereby authorize Quality Oil and its designated agents and representatives to conduct a comprehensive review of my background through, without limitation, a consumer report and/or that an investigative consumer report to be generated for review and consideration by Quality Oil. I understand that any such consumer report(s) may contain public record information, and such information may be requested from one or more consumer reporting agencies. These reports may include, but are not limited to, reports seeking the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, credit history, and criminal records. I further understand that such reports may contain public records information concerning previous driving record requests made by others from such state agencies, and provide driving records.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED TO FURNISH THE ABOVE-MENTIONED INFORMATION. To the extent required by law, I hereby expressly authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to the undersigned, to Quality Oil Company, LLC, or to its employees, representatives or agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

I further understand that this Disclosure Authorization and Release is made in connection with my application to engage in a commercial relationship with Quality Oil, as a prospective reseller of Petroleum Products supplied by Quality Oil. I understand that no commercial or contractual relationship with Quality Oil has been established with Quality Oil by executing this document or by providing the authorization and information supplied herein. No representations or promises have been made to me by Quality Oil in connection with my commercial application referenced herein. Quality Oil may, in its sole and absolute discretion, choose to not engage in business with me for any reason or no reason at all. I expressly waive any claim I have, or may have, to obtain information Quality Oil may have obtained through any reports mentioned herein. I also agree that I am not entitled to any explanation regarding Quality Oil’s decision to not engage in business with me, should that be its decision.
Signature*

Clear
Printed Name and Title*
Date*
Please verify that you are human*
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