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Tankwagon
Transport
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Transport Credit Application
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Company Name
*
Contact
*
Mailing Address
*
City
*
State
*
Zip
*
Fed Tax ID
*
Delivery Location
*
Delivery City
*
Delivery State
*
E-mail
*
Phone #
*
Fax #
Emergency #
*
Is PO Required?
*
Y
N
Are You Interested in Electronic Funds Transfer?
*
Y
N
Delivery Hours
*
Night Delivery?
*
Y
N
Directions / Special Instructions
Diesel (on road) (above ground) Tank Size
Diesel (on road) (under ground) Tank Size
Diesel (off road) (above ground) Tank Size
Diesel (off road) (under ground) Tank Size
Kerosene (on road) (above ground) Tank Size
Kerosene (on road) (under ground) Tank Size
Kerosene (off road) (above ground) Tank Size
Kerosene (off road) (under ground) Tank Size
Lead Free (above ground) Tank Size
Lead Free (under ground) Tank Size
Plus (above ground) Tank Size
Plus (under ground) Tank Size
Premium (above ground) Tank Size
Premium (under ground) Tank Size
Other (above ground) Tank Size
Other (under ground) Tank Size
Are off road tanks labeled Non-Hwy Use?
*
Y
N
Not applicable
All tanks clearly labeled for product?
*
Y
N
Do above ground tanks have pump?
*
Y
N
Not applicable
Permit: Facility ID # (for underground tanks)
Underground tank permit required by NC as of 7/1/96. We will contact you for a photocopy.
Permit: Certificate # (for underground tanks)
Permit: Expiration Date (for underground tanks)
Applicant(s) consents to a credit check based upon the information provided on this application for the purpose of extending credit. It is further understood and agreed by Applicant(s) that if credit is extended to Applicant(s), the terms of such credit account will be Net 10 days or Net 30 with 2-cent premium. Applicant(s) agrees to pay a finance charge of 1.5% per month which shall be added to any account not paid in full by due date. In the event of any default, Applicant(s) agrees to pay all costs of collection including reasonable attorney fees if incurred.
Applicant agrees to application terms
*
Applicant's Name
*
Applicant's Title
*
Application Date
*
Notes (internal use)
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