Online Credit Application | Brown Oil Company

Applicant Contact Name (required)

First Name

Last Name

Site Phone Number

Email

Address (required)

Country

Address Line 1

Address Line 2

City

State

ZIP Code

Type of Business

Number of Years in Business

Company Owner/Officer Name (required)

First Name

Last Name

Company Owner/Officer Address (required)

Country

Address Line 1

Address Line 2

City

State

ZIP Code

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

Country

Address Line 1

Address Line 2

City

State

ZIP Code

Sales Tax ID Number

Federal ID Number

Motor Fuel Distributor License Number

GATE Card Number

G-

Please provide a copy of card.

Name of Customer’s Bank

Customer’s Bank Primary Contact

First Name

Last Name

Customer’s Bank Address

Country

Address Line 1

Address Line 2

City

State

ZIP Code

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

Address

Country

Address Line 1

Address Line 2

City

State

Customer Credit Reference 2: Company Name

Customer Credit Reference 2: Address

Country

Address Line 1

Address Line 2

City

State

ZIP Code

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

Country

Address Line 1

Address Line 2

City

State

ZIP Code

Line

Site/Delivery Address

Country

Address Line 1

Address Line 2

City

State

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(required)

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

Signature of Owner/Office

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.

Date of Signature

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.

Credit Application

Customer Information

Signature of Applicant(required)