Product Credit Application

Applicant Information

Hidden

Date

MM slash DD slash YYYY

Hidden

IP address

Business Name

Name(Required)

First Last

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Enter Email Confirm Email

Website

Business Information

In Business Since(Required)

MM slash DD slash YYYY

Business Type(Required)

Government

Partnership/Sole Proprietorship

Corporation

Individual/Household

Federal Tax ID number ---OR---- Social Security Number(Required)

Credit Requested

Amount of Credit Requested(Required)

Business Handling

PO Number Required?(Required)

Yes

Terms(Required)

10 days/Cash/COD - 5% Lube Discount, .05/Gallon Fuels
Monthly - 2% Lube Discount, .02/Gallon Fuels

EFT 10 Days

EFT 30 Days

Cash/C.O.D.

This portion of the form authorizes Capital City Oil to be paid with an electronic bank transaction. You will need to upload a voided check below.

EFT 10 Days(Required)

I understand that all invoices on my account (including cardlock, tankwagon delivery, lube invoices, etc.) will be paid with an EFT 10 days after the invoice date and tankwagon fuel deliveries and cardlock fuel invoices will be discounted .05 cents per gallon and lubricants will be discounted 5%.

EFT 30 Days(Required)

I understand that all invoices posted to my account during the month (including cardlock, tankwagon delivery, lube invoices, etc.) will be paid with an EFT on the 10th of the following month and tankwagon fuel deliveries and cardlock fuel invoices will be discounted .02 cents per gallon and lubricants will be discounted 2%.

I (we) hereby authorize Capital City Oil, Inc., hereinafter called COMPANY, to initiate debit entries to my (our) account indicated below and the financial institution named below, hereinafter called FINANCIAL INSTITUTION, to debit the same to such account.

Financial Institution Name(Required)

Branch

Address(Required)

Street Address Address Line 2 City State ZIP Code

Type of Account:(Required)

Checking

Savings

Routing Number

Account Number

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity to act on it.

• All written debit authorizations must provide that the Receiver may revoke the authorization only by notifying the Originator in the manner specified in the authorization.

• Single entry reversals do not require authorization by the Receiver.

Company/Name(Required)

EFT Signature(Required)

Typed Name(Required)

Certificates

Sales Tax Exempt?(Required)

(If Yes, tax certificate will be required)

Yes

Certificate of Resale?(Required)

(If Yes, tax certificate will be required)

Yes

File

Drop files here or

Max. file size: 256 MB, Max. files: 2.

Purchasing Information

Services(Required)

Tankwagon Delivery

Cardlock (Fill out Attached Forms)

Lube Deliveries (Oil, Grease, DEF)

Transport Delivery

Ship To (If Different From Company Address)

Location Description/Name 1

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Location Description/Name 2

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Purchasing Contact

Name(Required)

First Last

Title

Phone(Required)

Email(Required)

Billing/AP Contact

Name

First Last

Title

Phone

Account Reference Information

Bank Name(Required)

Account Number(Required)

Contact(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

* CREDIT/TRADE REFERENCES MAY BE REQUESTED *

I HAVE READ AND UNDERSTAND THE CREDIT TERMS as stated on page 2 of this form and do hereby personally guarantee payment of any and all amounts due and owing to Capital City Oil, Inc. for use of the credit account issued via this credit application. All transactions involving the credit extended under this agreement shall be governed by the laws of the State of Kansas, which are expressly adopted to control all transactions hereunder.

Agreement to Terms and Conditions Signature(Required)

Date(Required)

S.S. Number(Required)

Home Address

Credit Terms

CREDIT TERMS

I submit the following information for consideration by Capital City Oil, Inc. (hereafter referred to as CCO) in order to establish a credit account for the above mentioned Company.

I hereby authorize the above listed Bank and/or Creditor to release the Company's financial information to CCO, and I authorize CCO to obtain credit reports from business reporting agencies and investigate the Company's credit now and in the future for updates to the account or to extend further credit. This information will be confidential and will only be used for the purpose of establishing credit or collecting amounts due to CCO.P>

Company Credit Release Signature

Initial(Required)

All purchases made on this charge account are due within ten days of each period billing date and failure to do so within thirty days may cause credit to be suspended and will cause a FINANCE CHARGE to be assessed. Any finance charges assessed due to late payment must be paid. The finance charge will be computed by applying to the adjusted balance a periodic rate of 1.5% per month corresponding to the ANNUAL PERCENTAGE RATE OF 18%. A $30.00 fee will be assessed on all returned checks and electronic funds transfers. In the event that it becomes necessary to pursue legal action for the collection of the account, I agree to pay reasonable attorney fees and all other collection charges.

Initial(Required)

As the holder of the cardlock card(s) I understand that I may be liable for the unauthorized use of the card(s). I will promptly notify CCO, orally or in writing, if a cardlock card is lost or being used by unauthorized persons. I understand my liability for unauthorized use of such card ends at 11:59 PM on the day of notification to CCO.

Initial(Required)

I understand when I give a cardlock card to an employee or friend; I authorized their use and am responsible for all charges to my account.

Initial(Required)

I understand the cardlock card(s) issued in my name shall be the property of CCO and may be canceled at any time by CCO, with or without notice. Upon cancellation of the cardlock card(s), I will surrender said card(s) immediately to CCO.

Initial(Required)

I understand CCO reserves the right to withdraw this credit privilege at any time for any reason and without notice. Further, CCO reserves the right to require a letter of credit. Such letter is subject to CCO’s approval. I agree to pay the account in full each billing period and recognize the FINANCE CHARGE charged in the event I fail to do so is in recognition of a possible event (my failure to do so), and not an expression of intent to create a revolving or installment charge account.

Initial(Required)

CCO may amend this agreement at any time by giving the written notice required by law to the customer whose name appears on the account by mailing a copy of such amendment to the customer’s last known address. All such amendments shall become effective as stated in the written notice and as allowed by law. CCO may at any time in the future amend the applicable FINANCE CHARGE and ANNUAL PERCENTAGE RATE on appropriate notice.

How did you hear about CCO?

Social Media

TV Commercial

Radio Commercial

Sales Person

Referral

Other

Referral Name

Salesperson

Terry

Scott

Jennifer

Hannah

Kevin

Thank you for choosing CCO as your petroleum Supplier.

Name

This field is for validation purposes and should be left unchanged.

Applicant Information

Business Information

Credit Requested

Business Handling

Certificates

Purchasing Information

Ship To (If Different From Company Address)

Purchasing Contact

Billing/AP Contact

Account Reference Information

Credit Terms

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