Sampson-Bladen Oil Welcomes You!

P.O. Box 469
Clinton, NC 28329
910-592-4177 or 800-849-4177

Commercial Customer Information

Name of Firm	Phone No.
Mailing Address	State Zip
Street Address	State Zip
Home Office Address	State Zip
Employer Identification Number or Social Security Number
Contact Person	Title
Email

Are you presently a CFN Cardholder?
Yes No
If Yes, Date and Card Last Used

Legal Structure:
Single Entity	Subsidiary	Corporation	Partnership	Other

If Subsidiary, Name, Address and Phone No. of Parent Company:

Please List Partners or Corporate Officers:

If in Business Less Than One Year, Please Give Former Employer Name and Address and Length of Employment:

If Individual or Proprietorship:
Owner	Spouse
Home Address	How Long
Home Phone	Have You Ever Filed Bankruptcy?
If Yes, When?	Where

References:
Bank Name and Branch	City State
Bank Officer
Acct#
Trade Reference
Tel#
Trade Reference
Tel#
Estimate of Gallons Used Per Month
Number of Vehicles	Number of Drivers
Agreement & Guarantee: I (we) have made the above statements for the purpose of obtaining credit. I (we) certify they are true and authorize you to make a credit investigation. Billings shall be issued twice monthly and payment is due in full within 10 days of invoice date. I (we) agree to pay a late charge of 1 1/2% per month on any delinquent balances. By submitting this information, I signify that I have read and understand the terms and conditions for cardlock use.