Credit Application

In this Application, "Applicant" or "you" means the business entity applying for credit with "Boyett Petroleum" or "us".
*All Starred Fields Are Mandatory

Company Information


*Legal Name of Business:

Fictitious Name of Business (DBA) if applicable:

*Tax ID:

*County, State Name Registered

Billing Address


*Street Address:

*State:

*City:

*Zip Code:

*County:

Delivery Address


*Delivery Street Address:

*State:

*City:

*Zip Code:

*County:

Size of Petroleum Tanks


*Diesel:

*Regular:

*Midgrade:

*Premium:

Primary Contact Information


*Primary Contact Person:

*Office Phone:

Fax:

*Title:

*Mobile/Other #'s:

*Email Address:

Additional Information


*Type of Organization (Please Select One):

*Type of Business:

*Have You Ever Declared Bankruptcy:

*State of Formation:

*Years in Business:

If Yes, Year of Bankruptcy:

State of Bankruptcy:

Property information


Does Applicant own or lease the property where fuel will be delivered?

If Own, year purchased:

Monthly Mortgage Payment:

If lease number of years left in lease:

Monthly rent:

Average Monthly Store Gross Sales (excluding lottery):

(For Retailers only) Average Monthly Fuel Sales:

(For Retailers only) Seller Permit Number:

(For Retailers only) Seller Permit Holder Name:

(For Retailers only) Seller Permit Holder Title:

Invoice Delivery


I prefer invoices to be delivered by:

Business Information


*Name of Owner/Officer

*Address, City, State, Zip

Social Security No.

*Title

*Phone


Name of Owner/Officer

Address, City, State, Zip

Social Security No.

Title

Phone


Name of Owner/Officer

Address, City, State, Zip

Social Security No.

Title

Phone

Fuel Supplier Credit References (Recommended, but not required.)


Name

Phone

City, State

Fax


Name

Phone

City, State

Fax


Name

Phone

City, State

Fax

List of Assets


Properties Held: Address

City, State

Value / Outstanding Debt

Properties Held: Address

City, State

Value / Outstanding Debt

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.

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 GUARANTY

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.


Name

Social Security No.

Title

Name

Social Security No.

Title

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

Account No.

Address, City, State, Zip

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