Credit Application Credit Application Credit Application In this Application, "Applicant" means the business entity applying for credit with Boyett Petroleum. Company Information Legal Name of Business * Tax Id * DBA (If Applicable) County Registered State Registered AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Billing Address Street Address * City * State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * County * Business Information Please use the "Add" button to add any other owners/members/officers to this application. Name of Owner/Member/Officer * Home Address, City, State, Zip * Title Phone * Social Security No. plus1 Add minus1 Remove Additional Information Type of Organization * Sole ProprietorPartnershipLLPLLCCorporationNon-ProfitGovernmentOther State of Formation * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Years in Business Type of Business * Invoice Delivery Preference Email Facsimile Have You Ever Declared Bankruptcy * Yes No Years of Bankruptcy State of Bankruptcy AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Primary Contact Information Information should be provided for contact in charge of general account maintenance and questions related to card activity. Full Name of Accounts Payable Contact * Title * Office Phone * Email * Mobile / Other Did you hear about us from one of our Salespeople? * Erica AlvarezRyan OstoreroNoneOther Fax Card Maintenance Contact Information Full Name of Card Maintenance Contact * Title * Office Phone * Email * Mobile / Other Fax Fleet Information Estimated Monthly Gallons Estimated Fleet Cards Estimated Vehicles Current Fleet Fuel Provider Trade References (recommended but not required) Name City State [none]AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Phone Fax plus1 Add minus1 Remove Authorization and Execution By completing this Application, Applicant acknowledges and agrees to have read in full our Credit Disclosure and agrees to comply with the Terms and Conditions set forth herein. Agreement I have read and accept the Credit Disclosure and Terms and Conditions By typing your name in the indicated fields, you are agreeing to conduct business electronically with Stan Boyett & Son, Inc., a California corporation dba Boyett Petroleum in accordance with the federal Electronic Signatures in Global and National Commerce Act (E-Sign), 15 U.S.C. ?? 7001, et seq. and California's Uniform Electronic Transactions Act, California Civil Code ?? 1633, et seq. Understand that transactions and/or signatures in records may not be denied legal effect solely because they are conducted, executed, or prepared in electronic form and that if a law requires a record or signature to be in writing, an electronic signature satisfies that requirement. Name Title ****Boyett Petroleum reserves the right to request additional information in completing its credit review of the Applicant.**** Personal guarantee and EFT are not required but may affect the approval of your application. Personal Guarantee For valuable consideration and to induce Boyett Petroleum to extend credit to Applicant, the undersigned Guarantor agrees: (1) to unconditionally guaranty Applicant's payment and performance of the Agreement (see reverse), including payment of all present and future debts owed to Boyett Petroleum by Applicant; (2) to waive notice of demands and notices of non-payment; (3) that the obligations of this Guaranty are joint and several and are independent from Applicant's obligations; (4) to waive all subrogation and recovery rights; (5) to pay attorneys' fees and costs incurred in enforcing this Guaranty; (6) that this Guaranty is binding upon his/her heirs and successors; (7) that his/her bankruptcy shall not affect his/her obligations to repay Boyett Petroleum; (8) that this Guaranty is deemed continuing and irrevocable; and (9) that Boyett Petroleum is authorized to obtain credit reports on the Guarantor and use said information in the evaluation in the credit of Applicant and authorizes Boyett Petroleum to run additional credit reports on Guarantor as may be needed from time to time in their credit evaluation and review process; and (10) to waive any right or claim under the Fair Credit Reporting Act in the absence of this continuing consent. Agreement I Agree I Do Not Agree Name Title Social Security Number plus1 Add minus1 Remove Payment Method EFT Payment Authorization I will use EFT I will pay another way EFT Payment Authorization Boyett Petroleum is authorized to initiate credit and debit entries electronically to Applicant's checking account listed below for properly supported charges. Bank Name Address, City, State Zip Account No. Routing No. This authorization is to remain in full force and effect until terminated by Applicant in writing and received by Boyett Petroleum; provided however, this authorization survives termination of the Agreement for any past due amounts owed by Applicant to Boyett Petroleum. This Authorization permits Boyett Petroleum to debit Applicant's account at frequent intervals for varying amounts up to the amount owed. Applicant acknowledges that the origination of electronic funds transfer ("EFT") transactions to this account must comply with the provisions of state and federal law. Boyett Petroleum will typically initiate payments on the due date or next business day. APPLICANT AGREES TO PAY BOYETT PETROLEUM A LATE PAYMENT FEE OF $80.00 FOR ANY EFT RETURNED FOR INSUFFICIENT FUNDS. Name Title Submit If you are human, leave this field blank.
