Credit Application Business Name: Other Trade Name: Web Address: Telephone: Fax: Contact Name: Contact Number: Mailing Address: City: Country: State: Zip: Business Address: City: Country: State: Zip: Parent Company or Headquarter Address: Dun & Bradstreet # Years in Business: Corporation (Privately held) Corporation(Publicly traded) Partnership Symbol Sole Proprietor Federal, State or local Gov’t. Federal ID #(Corporation or Government) Social Security #(All Others) Principle Officers, Partners, or Individual Proprietor: (attach additional page if necessary) Corporate Officer: Title: Corporate Officer: Title: Corporate Officer: Title: Bank Name: Bank Name: Contact Name: Contact Name: Account # Account # Phone # Phone # Reference Name Phone Fax Account # 1. 2. 3. 4. 5. 6. I Certify that I am authorized to make this request on behalf of this company. I understand the payment terms of R.P.M. Fuel L.L.C. are NET 30 and agree to pay all purchases according to these terms. I further agree this application is the property of R.P.M. Fuel L.L.C., and authorize R.P.M. Fuel L.L.C. to investigate credit and financial information through any credit bureau or by any other reasonable means including direct contact with past and present creditors and banking institutions. All past due accounts are subject to a finance charge that is the highest allowed by State Law, plus reasonable attorney‘s fees and costs of suit if the past due account(s) are placed for collection. Signed This Day Of Authorized Signature Title: Printed Name Valid Drivers License # and State: (Disregard for Corporation and Governments) Order Pending: No Yes Date: Requested Credit Line: R.P.M. Fuel L.L.C. Tank: No Yes Size: Pan: No Yes Other Equip:
