credit application

Customer Information

Applicant Contact Name

First Name

Last Name

Site Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Business

Number of Years in Business

Products & Frequency of Order

Company Owner/Officer Name

First Name

Last Name

Company Owner/Officer Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Company Owner/Officer Phone

(###)

###

####

Company Owner/Officer Social Security Number

Name of Other Business Fully or Partially Owned by Customer Requesting Line of Credit

Address of Other Business Fully or Partially Owned by Customern Requesting Line of Credit

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Sales Tax ID Number

Federal ID Number

Motor Fuel Distributor License Number

GATE Card Number

Please provide a copy of card.

Name of Customer's Bank

Customer's Bank Primary Contact

First Name

Last Name

Customer's Bank Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Customer's Bank Phone Number

(###)

###

####

Checking Account Number

Line

Customer Credit Reference 1: Company Name

Customer Credit Reference 1: Primary Contact

First Name

Last Name

Customer Credit Reference 1: Phone Number

(###)

###

####

Customer Credit Reference 1: Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Customer Credit Reference 2: Company Name

Customer Credit Reference 2: Primary Contact

First Name

Last Name

Customer Credit Reference 2: Phone

(###)

###

####

Customer Credit Reference 2: Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Customer Credit Reference 3: Company Name

Customer Credit Reference 3: Primary Contact

First Name

Last Name

Customer Credit Reference 3: Phone

(###)

###

####

Customer Credit Reference 3: Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Line

Site/Delivery Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Site Main Phone Number

(###)

###

####

Site Manager or Primary Contact

First Name

Last Name

Site Manager / Primary Contact Phone Number

(###)

###

####

Site Manager / Primary Contact Email

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Underground or Aboveground Storage Tank

Underground

Aboveground

If underground storage tanks, who is the owner?

Facility ID Number

Product 1 (gas or diesel) & Tank Size (gallons)

Product 2 (gas or diesel) & Tank Size (gallons)

Product 3 (gas or diesel) & Tank Size (gallons)

Product 4 (gas or diesel) & Tank Size (gallons)

Product 5 (gas or diesel) & Tank Size (gallons)

Line

Signature of Applicant

Tying your name in the fields below represents your signature and signifies that a credit line is being requested for the purpose of the purchase of petroleum-related products or for the rental of property. You certify that the statements made in this application are true. You understand that Brown Oil Company is relying on the above information for extending credit to the you, the Customer.

First Name

Last Name

Date of Signature

YYYY

Name

First Name

Last Name

Signature of Owner/Officer

Date

YYYY

Please provide a signed W-9 Form to Kim Padovano at Brown Oil Company and reference your company name in the subject line of the email. Thank you and we’ll be in touch after we have reviewed your submission.