Credit Application

JACOBUS ENERGY CREDIT APPLICATION
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A. ACCOUNT INFORMATION
Date*

MonthDayYear
Sales Representative

First NameLast Name
Legal Company Name*
Business Category*
Type of Business*
Trade Name (if different than above)
Federal ID Number*
Years in business*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Name (Accounts Payable)*
Phone (for Accounts Payable)*
Fax (for Accounts Payable)
Email (for Accounts Payable contact)*
Website address
B. TAX INFORMATION
Tax Exempt? (If yes, attach copy of Fuel Tax Exemption Certificate) IF TAX EXEMPTION CERTIFICATE IS NOT PROVIDED, TAX WILL BE ADDED TO INVOICES.*
D.U.N.S Number
Principal Name*

First NameLast Name
Principal SSN#*
Principal Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
IF COMPANY IS A SUBSIDIARY OR DIVISION, COMPLETE BELOW:
Parent Name

First NameLast Name
Parent Federal ID#
Parent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Delivery Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Name

First NameLast Name
Contact Phone Number

Area CodePhone Number
Contact Email
C. ESTIMATED USAGE
Estimated Gallons per Month*
Current Fuel Source
D. BANKING & TRADE REFERENCES
Primary Bank & Branch
Phone Number

Area CodePhone Number
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Account Number
Trade Reference - Vendor Name
Trade Reference Contact Name

First NameLast Name
Trade Reference Phone Number

Area CodePhone Number
Trade Reference Fax

Area CodePhone Number
Trade Reference City/State
E. FINANCIAL - Additional Information may be required. If so, a Jacobus Energy representative will contact you.
F. PAYMENT TERMS AND CONDITIONS
Electronic Signature for Payment Terms
Print Name*

First NameLast Name
Title*
Date

MonthDayYear
ONLY FILL OUT SECTION G IF YOU ARE ARRANGING FOR ACH DEBITS.
G. AUTHORIZATION AGREEMENT FOR PREARRANGED PAYMENTS (ACH DEBITS).
Company Name
Company I.D. #
Depository Name
Branch
City/State/Zip
Transit/ABA #
Account Number
Electronic Signature for ACH Withdrawal
Print Name

First NameLast Name
Title
Date

MonthDayYear
Should be Empty:

JACOBUS ENERGY CREDIT APPLICATION

A. ACCOUNT INFORMATION

B. TAX INFORMATION

C. ESTIMATED USAGE

D. BANKING & TRADE REFERENCES

E. FINANCIAL - Additional Information may be required. If so, a Jacobus Energy representative will contact you.

F. PAYMENT TERMS AND CONDITIONS

G. AUTHORIZATION AGREEMENT FOR PREARRANGED PAYMENTS (ACH DEBITS).