Company Name:

Contact First Name:

Contact Last Name:

Address:

Mailing Address
(if different)

City:

State:

Zip:

Phone:

Email:

Type of Company:

Name of Officers, Owners, or Partners:

Please List:

Bank Name, Address, and Individual to Contact:

Reference 1

Reference 2

Reference 3

By signing this form, it is agreed that credit inquiries can be made to verify the above information. As part of the credit investigation process Dunmore Oil Co. Inc. may request a credit report in connection with this application. Upon request, you will be advised whether a consumer report was obtained, and if such a report was obtained, you will be furnished with the name and address of the consumer reporting agency.

All merchandise shall be paid for upon delivery unless otherwise agreed in writing. In the event of an extension of credit, payment shall be made in full within agreed upon terms. A finance charge of two percent (2%) per month (24% for year) (or the maximum rate permitted to be charged under the applicable sale's law) will be imposed on amounts not paid as agreed. All expenses of collection, including reasonable attorney fees incurred by seller, shall be charged against the buyer in the event of late payments.

The undersigned has examined the above application for credit and certifies the information contained therein is true, accurate, complete and accepts the terms set forth herein.

Agree

Disagree

In consideration of the extension of credit by Dunmore Oil Co. Inc. to the above named customer for merchandise purchased upon the terms set forth above, the undersigned, jointly and individually (if more than one) unconditionally guarantees prompt payment and agrees to pay Dunmore Oil Co. Inc. upon demand and without previous recourse by it, to its remedies against the disclaimer, all amounts that may at any time be owning (including sums heretofore owing and now unpaid), and including finance charges, collection costs and attorney fees, if not paid at maturity by the customer. Notice of default is hereby waived.

Agree

Disagree