BILL TO:
Legal Company Name
Street Address
City
State
Zip
Telephone No.: Facsimile No.:
Accts. Payable Contact & Telephone No
Payment will be made by:
Invoice
Electric Funds Transfer (EFT)
Products you may be purchasing:
Fuels
Automated Fueling
Other
Federal ID No
Years in Business
Purchase Order Required	Yes No
Exempt Status (check all that apply) (All tax-exempt customers must have a signed certificate on file at Al Warren Oil, Co. or tax will be charged.)
Not Exempt
Sales Tax Exempt #
Federal Excise Exempt
State Excise Exempt
Type of Business
If a PROPRIETOR or PARTNERSHIP, please complete this section
Proprietor
Partnership
LLP
Partner or Proprietor Name
Street
City
State
Zip
Home Tel.
SS No.
Birth Date
If a CORPORATION, or LIMITED LIABILITY COMPANY, Please complete this section
C-Corp
S-Corp
LLC
Managing Member
President
Secretary
Vice President
Treasurer
Please give one bank and three commercial credit references
Bank Name
Bank City
Checking Acct No
Company Name Telephone No.
Company Name Telephone No.
Company Name Telephone No.
NOTICE TO CUSTOMER: Do not sign this before you read this agreement and the Payment Terms and Credit Policy, which is also part of this document. Credit line requested: $ Recent financial statement required for credit lines over: I understand the payment terms and credit policy of Warren Oil, Co. I authorize Warren Oil, Co. to contact any or all references listed above and further authorize these references to disclose financial information requested by Warren Oil, Co. I authorize Warren Oil, Co. to obtain information regarding my credit on a continuing basis. I authorize Warren Oil, Co. to provide information about my credit to a third party. I guarantee to pay all costs and expenses of legal or collection proceedings to collect any delinquent account, including reasonable attorney’s fees. I agree that collection or legal action may be taken in. I agree to notify Warren Oil, Co. in writing of any material change in any information set forth herein and provided herewith.
Authorized Representative
Title