Confidential Credit Application

Please complete all three forms:

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

"*" indicates required fields

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*

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

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