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Customer Credit Application

Thank you for your interest in D&H United Fueling Solutions. Please fill out our online credit application form below or download a hard copy here. Download PDF

Customer Credit Application

Step 1 of 5

20%

Choose the one:*
- For Individuals / Sole Proprietorships
- For Corporations, LLC's or Partnerships:
Individual Applying For Credit*
First Last
Social Security #*
Home Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone*
Sole Proprietorship?*
- Yes
- No
Legal Business Name*
Federal Tax ID #*
Majority Owner/Partner/Shareholder*
Business Type:*
- "S" Corporation
- "C" Corporation
- Limited Liability Co.
- Partnership
- Other

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Billing Information:*
- Tax Exempt
- Non - Tax Exempt Customer
D/B/A (If Applicable)
Business Phone*
Business Address*
Street Address City State / Province / Region ZIP / Postal Code
Business Email*
Physical Address*
Street Address City State / Province / Region ZIP / Postal Code
Are you the owner of this property?*
- Yes
- No
Do you own the fuel pumps?*
- Yes
- No
Amount of Credit Requested*
Years In Business*

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Banking Information (Please list banks with credit history) :
Bank #1 Name*
Name on Account*
Officer's Name*
First Last
Individual signer on account*
First Last
Bank Phone*
1st Account #*
2nd Account #
Bank #2
Bank #2 Name
Name on Account
Officer's Name
First Last
Individual signer on account
First Last
Bank Phone
1st Account #
2nd Account #

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Trade References Information (Please do not list COD accounts. Credit vendors only.)
Vendor #1 Name*
Name on Account*
First Last
Vendor Phone*
Account Number*
Vendor #2
Vendor #2 Name*
Name on Account*
First Last
Vendor Phone*
Account Number*
Vendor #3
Vendor #3 Name*
Name on Account*
First Last
Vendor Phone*
Account Number*

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Authorization To Check Credit
AUTHORIZATION TO RELEASE APPLICANT CREDIT INFORMATION Applicant hereby authorizes and instructs any person, bank or financial institution, consumer reporting agency or credit rating service to release to CREDITOR at any and all times upon request by CREDITOR any and all information that may be required for the purpose of a credit transaction. The current information is requested for the use in connection with a bona fide ''permissible purpose'' as defined in Section 54 of Public Law 91-508 and any lawful or permissible purpose allowed by the Fair Credit Reporting Act. A photocopy of this authorization shall be equivalent of the original and may be used as such. The undersigned hereby authorize CREDITOR to rely upon a facsimile copy of the signature. Applicant agrees to pay to CREDITOR interest at the rate of 18 percent per annum on any and all net amounts past due. For purposes hereunder past due shall mean any amount which is not paid within the period allowed by CREDITOR in accordance with the credit terms established by CREDITOR with Applicant, which may change from time to time. Applicant agrees that if CREDITOR institutes action to recover money on account of credit extended, that CREDITOR will be entitled to recover from Applicant, any and all costs of collection, including a reasonable attorney's fee. Applicant further agrees that this application is subject to and governed by the laws of the State of Texas and agrees to the jurisdictions and venue of Texas courts located in San Antonio, Bexar County, Texas should any collection action on Applicant's account be instituted.
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Authorization To Check Credit
AUTHORIZATION TO RELEASE APPLICANT CREDIT INFORMATION Applicant hereby authorizes and instructs any person, bank or financial institution, consumer reporting agency or credit rating service to release to CREDITOR at any and all times upon request by CREDITOR any and all information that may be required for the purpose of a credit transaction. The current information is requested for the use in connection with a bona fide ''permissible purpose'' as defined in Section 54 of Public Law 91-508 and any lawful or permissible purpose allowed by the Fair Credit Reporting Act. A photocopy of this authorization shall be equivalent of the original and may be used as such. The undersigned hereby authorize CREDITOR to rely upon a facsimile copy of the signature. Applicant agrees to pay to CREDITOR interest at the rate of 18 percent per annum on any and all net amounts past due. For purposes hereunder past due shall mean any amount which is not paid within the period allowed by CREDITOR in accordance with the credit terms established by CREDITOR with Applicant, which may change from time to time. Applicant agrees that if CREDITOR institutes action to recover money on account of credit extended, that CREDITOR will be entitled to recover from Applicant, any and all costs of collection, including a reasonable attorney's fee. Applicant further agrees that this application is subject to and governed by the laws of the State of Texas and agrees to the jurisdictions and venue of Texas courts located in San Antonio, Bexar County, Texas should any collection action on Applicant's account be instituted.
Please Type Applicant Name Here*
First Last
Title*
Date*
MM slash DD slash YYYY
Consent*
I agree that this electronic signature will be the electronic representation of my signature for all purposes, including legally binding contracts – just the same as a pen-and-paper signature.
Applicant Authorized Signature
Personal Credit Authorization
THE FOLLOWING SECTION IS TO BE COMPLETED BY THE OWNER, MAJOR SHAREHOLDER, MAJORITY PARTNER OR MAJORITY MEMBER OF APPLICANT ACTING IN HIS/HER INDIVIDUAL CAPACITY
AUTHORIZATION TO RELEASE PERSONAL CREDIT INFORMATION The undersigned hereby authorizes and instructs any person, bank or financial institution, consumer reporting agency or credit rating service to release to CREDITOR at any and all times upon request by CREDITOR any and all information which may be required for the purpose of a credit transaction. The current information is requested for the use in connection with a bona fide ''permissible purpose'' as defined in Section 54 of Public Law 91-508 and any lawful or permissible purpose allowed by the Fair Credit Reporting Act. A photocopy of this authorization shall be equivalent of the original and may be used as such.
Please Type Applicant Name Here*
First Last
Date*
MM slash DD slash YYYY
Consent*
I agree that this electronic signature will be the electronic representation of my signature for all purposes, including legally binding contracts – just the same as a pen-and-paper signature.
Principle Individual Signature*
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Corporate Office:
8559 E North Belt
Humble, TX 77396

Telephone: (713) 747-5952
FAX: (210) 651-3884
E-mail: [email protected]

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