Business Credit

Confidential Business Credit Application

Name of Business:			* If Corporation, Date and State of Incorporation:
Street Address:			Month: Year: State:
City:
State & Zip Code:
Telephone No.
Fax #
Tax ID #
E-mail Address:
Delivery Address: (if different from above.)
City:			Nature of Business
State & Zip Code:
Years in Business:			Name(s) of individual(s) responsible for payables
Years at current address:

Principals of Business

#1		#2
Name:		Name:
Title:		Title:
SS#:		SS#:
Home Address:		Home Address:
City:		City:
State & Zip Code:		State & Zip Code:

If Tax Exempt, Tax Exemption #:

Has your company or any of it's owners, officers, or partners ever filed a voluntary petition of bankruptcy, been adjudged, bankrupt, or made an assignment for benefit of creditors? YES NO

Has a tax lien been filed against your company, or any of it's owners, officers, or partners within the past five (5) years?

YES	NO	If Yes, Explain:

Is your company presently doing business under another name? YES NO
If yes, provide name(s):

Fuel to be delivered: #2 Fuel Oil On Road Diesel Off Road Diesel Gasoline
List storage tank size(s):

Trade References

#1		#2
Name:		Name:
Address:		Address:
City:		City:
State & Zip Code:		State & Zip Code:
Phone:		Phone:
Fax:		Fax:

Bank References

Bank Name:		Account #:
Address:		Contact:
City:		Phone:
State & Zip Code: