340 4th Street
Ewing, NJ 08638-2750

ACCOUNT REQUEST A QUOTE

Commercial Credit

FORM VOID UNLESS COMPLETE INFORMATION IS SUPPLIED

Business Name

Street Address

City

State:

Zip

FED ID #

Phone #

Fax #

Type of Business

Years in business

Own Building?

Own

Rent

Landlord

Phone #

Sales Tax Exempt

Yes

Sales Tax Exemption #

Purchase Order Required?

Yes

If sales tax exempt, please complete and submit appropriate Tax Exemption Form

Accounts Payable Contact

Title

Bills Paid By

Invoice

Statement

Phone

Ext.

Principal's Name

Social Security #

Residence Address

City

State:

Zip

Bank References

Bank Name

Bank Address

Checking Account

Savings Account

We authorize you to release information concerning the noted account(s) with your bank/company to Hough Petroleum for the purpose of credit verification.

The undersigned individual(s) who is either a principal of the credit applicant, or a sole propriertorship of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, hereby consents to and authorizes the use of a consumer credit report on the undersigned by the above named business credit grantor, from time to time as may be needed, in the credit evaluation process.

Digital Signature 1 (pending confirmation)

Date

Digital Signature 2 (pending confirmation)

Date

Credit References

Name

Phone #

Address

Fax #

Name

Phone #

Address

Fax #

Name

Phone #

Address

Fax #

Customer Survey - Please Complete

How did you hear about Hough Petroleum?