Customer Credit Application Thank you for your interest in D&H United Fueling Solutions. Please fill out the credit application form below to process your application. Customer Credit Application Step 1 of 5 20% Choose the one:*For Individuals / Sole ProprietorshipsFor Corporations, LLC's or Partnerships:Individual Applying For Credit* First Last Social Security #*Home Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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 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* 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 #2Bank #2 NameName on AccountOfficer's Name First Last Individual signer on account First Last Bank Phone1st Account #2nd Account # 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 #2Vendor #2 Name*Name on Account* First Last Vendor Phone*Account Number*Vendor #3Vendor #3 Name*Name on Account* First Last Vendor Phone*Account Number* Authorization To Check CreditAUTHORIZATION 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.Authorization To Check CreditAUTHORIZATION 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* Date Format: 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 SignaturePersonal Credit AuthorizationTHE FOLLOWING SECTION IS TO BE COMPLETED BY THE OWNER, MAJOR SHAREHOLDER, MAJORITY PARTNER OR MAJORITY MEMBER OF APPLICANT ACTING IN HIS/HER INDIVIDUAL CAPACITYAUTHORIZATION 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* Date Format: 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*CAPTCHA