52 State Highway 33
Hamilton, NJ 08619

ACCOUNT REQUEST A QUOTE

Dealer Credit Application

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

Landlord Phone #

Principal's Name

Social Security #

Residence Address

City

State

Zip

Principal's Name

Social Security #

Residence Address

City

State

Zip

Bank References

Bank Name

Bank Address

Bank Telephone #

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?

Personal Financial Statement

ASSETS

Checking Account

Bank Name

Bank Address

Bank Telephone Number

Account Number

Savings/Money Market Account

Bank Name

Bank Address

Bank Telephone Number

Account Number

Securities (Current Market)

Tools & Equipment

Real Estate

LIABILITIES

Unsecured Notes (Name, Address and Telephone Number)

Unsecured Note 1

Unsecured Note 2

Contracts & Secured Loans Payable

Contract/Loans Payable 1

Contract/Loans Payable 2

Open Accounts Payable

Name

Account Number

Address

Telephone Number

Name

Account Number

Address

Telephone Number

Real Estate Mortgages

Lean Holder's Name 1

Address 1

Lean Secured by 1

Lean Holder's Name 2

Address 2

Lean Secured by 2

Other Liabilities (Describe)