Confidential Credit Application

Please complete all three forms:

IRS Form W-9
Confidential Credit Application
Authorization Agreement Direct Payments (ACH Debits)

General Information
Business Name*
Legal Name for Billing (if different than Business Name)
Address*
Street Address City State ZIP Code
Phone*
Fax
Email*
Enter Email Confirm Email
Website
Business Profile
Buyer's Name*
First Last
Accounts Payable Contact
First Last
Date Business Started or Purchased*
MM slash DD slash YYYY
Year at Present Location*
Is this business a subsidiary of, or affiliated with, any other business? If yes, please list name.
Have you or your business operated under any other name in the past 5 years?*
Name, address & phone number of former business
Have you or your company every been in bankruptcy? If yes, which chapter?*
If yes, give company name, address & approximate date of bankruptcy
Form of Business*
If Corporation, which state was it formed?*
Requested Line of Credit $*
Is the business in Dun & Bradstreet?*
- Yes
- No
List Owners, Partners & Corporate Officers
1. Name and Title*
Home Address*
Phone*
Social Security Number*
2. Name and Title
Home Address
Phone
Social Security Number
3. Name and Title
Home Address
Phone
Social Security Number
Business References
1. Company Name*
Company Address*
Phone*
Fax*
Account Number*
2. Company Name*
Company Address*
Phone*
Fax*
Account Number*
3. Company Name*
Company Address*
Phone*
Fax*
Account Number*
Applicant Bank Information
Bank Name*
Bank Address*
Phone*
Fax*
Account Type*
- Checking
- Savings
Account Number*
Shepherd Oil Company will begin processing this application as soon as it is received and will hold all information in strict confidence.

TO EXPEDITE, PLEASE MAKE SURE THE ENTIRE APPLICATION IS COMPLETE AND SIGNED BY AN AUTHORIZED SIGNATORY OF THE BUSINESS.
Email of Signatory*
Enter Email Confirm Email
Uniform Electronic Transactions (UETA) Compliance
Consent to Electronic*
I am consenting to complete and receive, by electronic means, including through the email address provided above, communications regarding my application, including notice of your decision on my application as well as important account opening information regarding rates, fees, and other costs related to the account for which I am applying. I understand that these electronic disclosures may not be available in any paper or non-electronic form, so if I would like to retain a copy for my records, I may print or download these disclosures during this application process. I understand that to access and retain these electronic disclosures I must have or have access to the following hardware and software: (1) a computer or mobile device with Internet or mobile connectivity and an operating system; (2) an Internet browser that supports HTML 4.0, SSL encryption and JavaScript (e.g., the latest version of Internet Explorer, Firefox, Chrome or Safari); (3) software capable of opening documents in PDF format; (4) access to the email address I provided above; and (5) sufficient storage space to save Communications or a printer to print them. I understand that I must consent to receive these materials electronically to submit this application.
Consent to Electronic
Acknowledgement*
Shepherd Oil Company will begin processing this application as soon as it is received and will hold all information in strict confidence. TO EXPEDITE, PLEASE MAKE SURE THE ENTIRE APPLICATION IS COMPLETE AND SIGNED BY AN AUTHORIZED SIGNATORY OF THE BUSINESS. I, the undersigned, certify that I am an authorized Signature of the applicant, and can disclose information on behalf of the applicant and that all the information provided is true and correct. I hereby authorize Shepherd Oil Company or any agency or credit bureau employed by them, to investigate any references or other data obtained from me or from any other source. I authorize the references listed to provide any information requested by Shepherd Oil Company. I understand and agree that the applicant shall adhere to Shepherd Oil Company’s set terms and credit limits and that payment in full is due within the terms granted by Shepherd Oil Company. Any invoice not paid within the terms set by Shepherd Oil Company will be subject to a late fee of 1% on all overdue balances. Furthermore, I understand and agree that in the event Shepherd Oil Company, by reason of the account's delinquency and/or any reasonable reason, place the account with a collection agency or with an attorney, I will pay all costs, collection fees, and attorney fees incurred by Shepherd Oil Company.
Acknowledgement
Signature*
Name of Signatory*
First Last
Title*
Today's Date*
MM slash DD slash YYYY
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Comments
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