Electronic Credit Application for Fleet Services

Information collected in this electronic form is submitted directly to contact@eoctricities.com, the official email address for Express Oil Change in Kingsport / Tri-Cities TN. Should you have concerns about submitting your form electronically, you can download a pdf document here to submit to Express Oil Change through fax or postal mail.

The majority of fields in this form are required for electronic submission, however should you have special needs, questions or requests there is an open text field near the end for Special Requirements where you can enter that information.

Date

Date this form is being submitted

YYYY

Business Name

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Ownership:

Please select your company's type of ownership

Name of Parent or Holding Company

Owner(s)/Officer(s) Name / Address

BANKING & FINANCIAL INFO

Bank / Branch Name

Bank Acct #

Bank Contact NameBank

Bank Phone Number

(###)

###

####

Federal ID#

Please provide your company's Federal ID #

State Sales Tax #

Please provide your company's state sales tax number if you are a tax exempt organization

Years in Business

Please provide the number of years your company has been in business

LOCAL TRADE REFERENCES

You must provide this info for your reference: Company Name / Account # / Fax Number #

VEHICLE & PAYMENT INFO

Number of Company Vehicles

Do you prefer to be BILLED or PAY at TIME OF SERVICE?

Do you require a Purchase Order?

If you answered yes above, do you want your Purchase Order in written or verbal form?

Do you want invoices emailed or sent via postal mail?

If email, provide email addres of supervisor and/or accounts payable:

Do you require any of the following on your invoices? (check all that apply)

Driver's Name

Vehicle #

Plate Number & State

VIN

None of the above

Please state any other special requirements needed for billing:

Name of person to contact if we have a question regarding your account or an invoice:

First Name

Last Name

Phone Number of the person you noted above

(###)

###

####

Email address of the person you noted above

AGREEMENT & GUARANTEE

Agreement (IMPORTANT - READ CAREFULLY)

In submitting this form you agree to the following: As an authorized agent of the business applying for credit (hereinafter "applicant"), I understand that this credit application authorizes Guidry's Oil Company, LLC to check all credit and business associations of applicant. Furthermore, I understand that if applicant is granted credit, the following agreements are made in consideration of that extension of credit: 1) All purchases will be paid for in accordance with the terms of sale; 2) If applicant fails to pay for said purchases when due, the applicant agrees to pay and authorizes the assessment of interest charges of 1.5% per month (18% per annum) on any past due amounts; and 3) In the event that a lawyer or collection agency is used to collect a delinquent account, applicant understands and agrees to pay all collection costs including court cost fines, and reasonable attorney fees.

Personal Guarantee (IMPORTANT - READ CAREFULLY)

In submitting this form you agree to the following: In consideration of credit being extended by Guidry's Oil Company, LLC, to the above named applicant the undersigned guarantor hereby contract and guarantee to Guidry's Oil Company, LLC, the faithful payment, when due of all monies owned by the above named applicant. In the event this account is placed for collection in the hands of an attorney, I agree and promise to pay for the cost of collection and reasonable attorney fees.

Today's Date

This date signifies that I have read and will abide by the Agreement and Personal Guarantee I have electronically signed my name to above

YYYY