Credit Application - Dine-Aglow Diablo Food Service Fuels

Credit Application

Business Details - Step 1 of 6

Exact Business Name of Applicant:

Business Type (check one):

Corporation
Partnership
Sole Proprietor

Business Address:

Address Line 1

City

State / Province / Region

Postal Code

Country

Business Phone:

Business Fax:

Business Email:

Shipping Address:

Address Line 1

City

State / Province / Region

Postal Code

Country

Dun & Bradstreet #:

EIN #:

Does your company use Purchase Orders?

If Subsidiary or Division, please indicate relationship to Main Office

Name:

First

Last

Address:

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone:

Fax:

Email:

Relationship:

Contact:

Business Status Details

Annual Sales:

# of Employees:

How long in business?

Tax Status:

Bank Reference

Bank Name:

Address:

Address Line 1

City

State / Province / Region

Postal Code

Country

Bank Phone:

Bank Fax:

Account Number:

Bank Contact:

Bank Contact's Email Address: *

Trade References

Trade Reference #1 - Name:

First

Last

Trade Reference #1 - Address:

Address Line 1

City

State / Province / Region

Postal Code

Country

Trade Reference #1 - Phone:

Trade Reference #1 - Fax:

Trade Reference #1 - Account #:

Trade Reference #1 - Contact:

Trade Reference #1 Contact's Email Address: *

Trade Reference #2 - Name:

First

Last

Trade Reference #2 - Address:

Address Line 1

City

State / Province / Region

Postal Code

Country

Trade Reference #2 - Phone:

Trade Reference #2 - Fax:

Trade Reference #2 - Account #:

Trade Reference #2 - Contact:

Trade Reference #2 Contact's Email Address: *

Trade Reference #3 - Name:

First

Last

Trade Reference #3 - Address:

Address Line 1

City

State / Province / Region

Postal Code

Country

Trade Reference #3 - Phone:

Trade Reference #3 - Fax:

Trade Reference #3 - Account #:

Trade Reference #3 - Contact:

Trade Reference #3 Contact's Email Address: *

Message

If Subsidiary or Division, please indicate relationship to Main Office

Business Status Details

Bank Reference

Trade References

Terms and Conditions: