Credit Application for Dealer / Commercial
Credit Application
 
Please fill out the credit application below:
* indicates a required field
 
Business / Commercial / Dealer Account
 
* Business Name:
 
* Business Address:
 
 
* Shipping Address:
 
 
* Phone:
 
Fax:
 
PO's Required:
 
* Billing Contact:
 
* Email:
 
* Invoice Delivery:
 
Type of Business:
 
 
 
If Incorporated, Corporation Name:
 
Date of Incorporation:
 
Fed ID:
 
State ID:
 
D&B #:
 
 
 
Principal Owners, Officers, or Stockholders
 
* Name:
 
Title:
 
* Home Address:
 
 
* Phone:
 
Mobile:
 
* Email:
 
* Date of Birth:
 
* Social Security #:
 
* Driver's License #:
 
* Driver's License State:
 
Additional Owner, Officer, or Stockholder
 
Name:
 
Title:
 
Home Address:
 
 
Phone:
 
Mobile:
 
Email:
 
Date of Birth:
 
Social Security #:
 
Driver's License #:
 
Driver's License State:
 
 
 
Bank Information
 
* Bank Name:
 
* Bank Address:
 
 
* Person to Contact:
 
* Phone:
 
* Account #:
 
 
 
Business References
 
* Name:
 
* Address:
 
 
Acct #:
 
Phone:
 
Additional Reference
 
Name:
 
Address:
 
 
Acct #:
 
Phone:
 
Additional Reference
 
Name:
 
Address:
 
 
Acct #:
 
Phone:
 
 
 
* Sales Tax:
 
 
 
 
Certification Statements
 
Will you be buying off-road #2 diesel fuel?:
 
 
 
 
Check YES or NO:
 
 
If YES, my facility ID # is:
 
 
 
Check YES or NO:
 
 
 
 
Check YES or NO:
 
 
 
 
I agree to the following statements:
 
* Agreement:
 
 
 
 
* Business Name:
 
* Name:
 
* Social Security #:
 
* Electronic Signature (email):
 
* Title:
 
* Signed Date:
 
Additional Signee
 
Name:
 
Social Security #:
 
Electronic Signature (email):
 
Title:
 
Date Signed:
 
 
 
* Security Phrase:
Please enter the text as it appears below:
 
* Security Check:
 
 
 
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