If you are tax exempt, please fax the appropriate form to 330-833-1031
Delivery Address (If different from mailing)
Officers and/or Principals
1st Referral Company Name:
2nd Referral Company Name:
3rd Referral Company Name:
Product(s) You Are Interested In? (Check all that apply):
Applicants Statement and Agreement:
The above information as well as that given is for the purpose of obtaining credit and is warranted to be true. I/We hereby authorize the firm to whom this application is made to investigate the references listed pertaining to my/our credit and financial responsibility.
In consideration of credit being extended to the undersigned or anyone on his or their behalf, the
undersigned agrees without offset, to pay for the same promptly when due. It is agreed that all
invoices and delivery tickets, whether signed or not, shall be deemed true and accurate unless
alleged discrepancies are reported in writing to Campbell Oil Company within five (5) days of its date.
Any balances more than 10 day terms will be assessed a late charge or finance charge in the amount
of a maximum of 1% monthly until payment in full is made, which is an annual percentage rate of
12%. Purchases and deliveries are herewith authorized to be made without signature.
I hereby authorize any person, association, firm, bank or Corporation to furnish on request to
Campbell Oil Company information concerning our credit.
I/We agree to provide durable roadway, safe unobstructed access to tank fill and no hazards due to
animal or person.