The information requested below is for use of our credit department in expediting your credit and will be kept confidential.  You can also view and print our Adobe PDF version of this application, fill it out, and FAX it to 757-934-0538 or mail it to:

Supreme Petroleum, Inc.
1200 Progress Road
P.O. Box 1246
Suffolk, Virginia 23434

Thank you for your cooperation in furnishing all pertinent data and hope that you find these options as a convenience.

 

INDIVIDUAL ACCOUNT - You assume liability for purchases.  Credit data may be reported only in your name. An applicant, although married, may apply for an individual account.
DESIGNATED USER ACCOUNT - If your spouse will use this account, please provide spouse's full name.  If spouse will not use account, designate other user, if any.  Fill in all of the application.
JOINT ACCOUNT - Fill in all of the application.  Both applicants assume liability for all purchases.  Credit data may be reported in both names subject to federal and your own state laws.
COMMERCIAL ACCOUNT - You may request a commercial credit card account by completing the application using the name of an authorized company representative.  
COMPANY INFORMATION (Commercial Accts):
Name Of Company
Billing Address
Floor/Suite
City
State
Zip
Work Telephone
Fax Telephone
Buyer's Name
Buyer's Email
Owner/President
Owner's Email
Acct's Payable Phone Ext.
Ownership
Corporation Partnership Other
Nature Of Business
FIN #
How Long In Business? Years
INDIVIDUAL INFORMATION:
Name
Billing Address
City
State
Zip
Home Telephone
Work Telephone
Email
Date Of Birth
Social Security Number
Present Employer
Employer's Address
Occupation
CO-APPLICANT INFORMATION:
Name
Billing Address
City
State
Zip
Home Telephone
Work Telephone
Email
Date Of Birth
Social Security Number
Relationship To Applicant
NEAREST RELATIVE NOT LIVING WITH YOU:
Name
Address
City
State
Zip
Home Telephone
Work Telephone
Relationship To Applicant
Bank 1 Reference
Company Bank
Account Number
Date Opened
Bank Contact
Type Of Acct.
Checking Saving Loan
Bank 2 Reference (if applicable)
Company Bank
Account Number
Date Opened
Bank Contact
Type Of Acct.
Checking Saving Loan
Trade References
Reference 1
Company
Address
Address2
Contact Name
Phone
Email
Account Number
Opening Date (MM/YY)
Balance
Monthly Payment
Reference 2
Company
Address
Address2
Contact Name
Phone
Email
Account Number
Opening Date (MM/YY)
Balance
Monthly Payment
Reference 3
Company
Address
Address2
Contact Name
Phone
Email
Account Number
Opening Date (MM/YY)
Balance
Monthly Payment



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