Application For Credit

Your Information

• Name of Firm or Individual
• Address (Physical & P.O. Box)
• City                                                                                                                                                   ST                 Zip
• Telephone                                                            Fax                                                                        

Please list three credit references

Please include business name, complete address, phone & fax number of reference

• First Reference
• Second Reference
• Third Reference

Financial Information

• Financial Institution
• Bank Officer
• Bank Address and Phone
• Dunn and Bradstreet Rating
• Federal I.D. Number
• Name(s) of Principal Owner (s)

Terms and Conditions

• Terms: net 30 days 1.5% assessed on past due accounts.
• We certify that all the information on this form is accurate and hereby authorize you to contact any listed reference or financial institution on this application for the purpose of verifying and establishing an account with ATM Oil Co., Inc./ Jim's Tank Service, LLC.
• Failure to make payment within thirty days is basis for legal action to be taken and signer agrees to pay all court costs, reasonable attorney fees and any accrued interest on the past due account. Signer hereby waives all rights of exemption under the laws of the state of residence.

Sign and Date

• Signature and Title                                                                                                                                                   Date