Credit Application | Lott Oil Company | Oil and Gas Distributor in Louisiana

Corporate Information

Company Name *

Billing Address *

Street Address Address Line 2 City State ZIP Code

Phone Number *

Is this Company a: *

Corporation

Partnership

Sole Proprietor

Limited Liability Company

Other

Accounts Payable Contact *

Accounts Payable Email *

If Contractor, Bonded?

Yes

If Incorporated, what state?

Nature of Business

Years in Business

Website

Federal ID

Other Business Names You Have Operated Under

Dunn & Bradstreet

Desired Credit *

Method of Payment *

Cash

Check

EFT/ACH

Credit Card*

*Fee may apply on payments made by credit card

Desired Terms

COD

Net 5

Net 7

Net 10

Net 20

Net 30

To be Filled out by Lott Oil Credit Department

This field is hidden when viewing the form

Master Account Number (Internal)

This field is hidden when viewing the form

Approved By (Internal)

This field is hidden when viewing the form

Approved Terms (Internal)

This field is hidden when viewing the form

Profit Center Responsible (Internal)

Alexandria

Bossier City

Leesville

Mansura

Many

Monroe

Natchitoches

Winnfield

Personal Credit Information

Complete the following for all owners and partners.

Name *

Address *

Phone *

Email *

Social Security Number *

Have you ever filed for bankruptcy? *

Yes

Name

Address

Phone

Social Security Number

Have you ever filed for bankruptcy?

Yes

Personal Credit Information (Cont.)

Name

Address

Phone

Social Security Number

Have you ever filed for bankruptcy?

Yes

Name

Address

Phone

Social Security Number

Have you ever filed for bankruptcy?

Yes

Banking & Insurance

Principal Bank *

Address *

Street Address Address Line 2 City State ZIP Code

Loan Officer *

Phone Number *

Email Address

Insurance Company

Address

Agent

Phone Number

Email Address

Trade References

Please provide the names and phone numbers of at least 3 credit references that we may contact. If approval needs expediting, please provide us with references that will give credit ratings over the phone to prevent delays.

Name *

Phone Number *

Email Address

Name *

Phone Number *

Email Address

Name *

Phone Number *

Email Address

Shipping Information

Same as Billing? *

Yes

Company Name *

Phone Number *

Shipping Address *

Street Address Address Line 2 City State ZIP Code

On-Site Contact

On-Site Email Address

On-Site Cell

PO Required? *

Yes

Blanket PO

Inside City Limits? *

Yes

To be completed by LOC Account Representative

This field is hidden when viewing the form

Products to be Purchased

Conv. Gas

E10 Gas

On Road

Off Road

NonFL

Tank 1 Information

This field is hidden when viewing the form

Provided By

Lott Oil Co.

Customer

This field is hidden when viewing the form

Type of Tank

Above Ground

Underground

This field is hidden when viewing the form

Product

This field is hidden when viewing the form

Dimensions/Capacity

Tank 2 Information

This field is hidden when viewing the form

Provided By

Lott Oil Co.

Customer

This field is hidden when viewing the form

Type of Tank

Above Ground

Underground

This field is hidden when viewing the form

Product

This field is hidden when viewing the form

Dimensions/Capacity

Tank 3 Information

This field is hidden when viewing the form

Provided By

Lott Oil Co.

Customer

This field is hidden when viewing the form

Type of Tank

Above Ground

Underground

This field is hidden when viewing the form

Product

This field is hidden when viewing the form

Dimensions/Capacity

Freight

This field is hidden when viewing the form

LOC Account Rep

This field is hidden when viewing the form

Primary Terminal

This field is hidden when viewing the form

Secondary Terminal

This field is hidden when viewing the form

Pricing Formula

This field is hidden when viewing the form

Ship to Account Number

This field is hidden when viewing the form

Freight Code

This field is hidden when viewing the form

Pump Off Required?

Yes

This field is hidden when viewing the form

Date Ship to Acct. Established

If additional shipping locations or tank info is required, please print additional sheet.

Taxing Information

This field is hidden when viewing the form

Tax Rate

This field is hidden when viewing the form

Jurisdiction

This field is hidden when viewing the form

Sales Tax Exempt?

Yes

This field is hidden when viewing the form

Local Gov't Excise Tax Exempt?

Yes

Terms and Conditions

This application is submitted by the undersigned (hereinafter referred to as the Applicant) for the purpose of maintaining a credit account with Lott Oil Company, Inc. (hereinafter referred to as individually or collectively as Creditor). All representations are accurate, complete and truthful to the best of the Applicant's knowledge and belief. The Applicant hereby authorizes any individual, form or corporation given as credit references to disclose to the Creditor orally or in writing any information, which is pertinent to this application. If the Applicant is a corporation, partnership, or LLC (hereinafter Entity), the undersigned affirmatively states that he/she is authorized to make application on behalf of said Entity and to obligate the same for any credit extended thereto as a result of this application, and further that the Entity on whose behalf the application is hereby made will continue to be bound and obligated for any credit advanced hereto until notice to the contrary is given in writing via certified mail return receipt requested to the Creditor at 1855 South Drive, Natchitoches, LA 71457. Applicant authorizes Creditor to obtain a credit profile report from a credit agency. Credit extended by Creditor to Applicant shall be due within the terms stated on each invoice. Applicant agrees to pay the amount due on or before the due date to avoid a LATE CHARGE. All accounts not paid by the due date shall be deemed past due and a late charge shall be added to the past due balance. A FINANCE CHARGE of 1.5% per month (ANNUAL PERCENT RATE OF 18%) on the outstanding amount shall be charge on any amounts due to the Creditor that is not paid by the due date on any notice of amounts due from Applicant. It is expressly understood by Applicant that the existence of the FINANCE CHARGE does not affect Applicant's obligation to pay the account in full when due. At the election of the Creditor, Applicant may be required to remit payments via Electronic Funds Transfer (EFT). Upon Creditor's request, Applicant will submit all information necessary for processing transactions via EFT and execute any and all documents required for the payment via EFT. If this account is not paid in full when due it is placed in the hands of an attorney for collection. Applicant agrees to pay reasonable attorney's fees in the amount of at least twentry-five percent (25%) additional on the aggregate amount of principal, late charges, finance charges, all court costs incurred, and all collection expenses incurred. Applicant and Creditor agree that the exclusive venue for the litigation of any and all disputes that may arise from, be related to, or be connected with this agreement, or its terms and conditions, shall be in the district court of Natchitoches Parish, Louisiana, which shall likewise have exclusive jurisdiction of such disputes. Applicant and Creditor agree that Louisiana Law shall govern the interpretation of this agreement. Payments returned for any reason, will be subject to a return payment fee of $30.00. Any references to Applicant herin also apply to any guarantors. Terms and Conditions can be changed at any time by Creditor with written notice.

NOTICE: DO NOT SIGN THIS AGREEMENT UNTIL YOU HAVE READ IT. YOU ARE ENTITLED TO A COPY OF THE SIGNED AGREEMENT.

Signature *

Title *

Printed Name *

Guarantee

For value received, the undersigned, who is made party to this contract and is bound with applicant jointly and in solido for the faithful execution of all obligations to be performed on the part of the Applicant, does hereby guarantee payment of all amounts advanced by Creditor to Applicant. Applicant and Guarantor specifically waive division.

Signature *

Guarantor's Printed Name *

Guarantor's Date Signed

Guarantor's Principal Bank

Guarantor's Title

Guarantor's SSN *

Guarantor's Date of Birth

This field is for validation purposes and should be left unchanged.