Commercial Credit Application

Business Name:*

Street Address:*

State:*

Phone #:*

Email:*

Years in Business:*

Sales Tax Exemption #

Fed EIN #:*

City*

Zip:*

Fax #:

Type of Business:*

Sales Tax Exempt*

Yes

** If sales tax exempt, please attach Exemption Certificate(s)

Purchase Order Required?*

Yes

Accounts Payable Contact*

Title*

Ext.

Pay by ACH?*

Yes

If yes, we’ll send you our banking information

City*

Zip*

Bills Paid By:*

Invoice

Statement

Phone #*

Principal’s Name*

Residence Address*

State*

Bank References

Bank Name*

Bank Address*

Checking Acct #*

Savings Acct #*

By checking this box, we authorize you to release information concerning the noted account(s) with your bank/company to Naughton Energy for the purpose of credit verification.

The undersigned individual(s) who is either a principal of the credit applicant, or a sole proprietorship of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, hereby consents to and authorizes the use of a consumer credit report on the undersigned by the above named business credit grantor, from time to time as may be needed, in the credit evaluation process.

Signature*

Signature

Credit References

Name:*

Address:*

Name:

Address:

Name:

Address:

Phone:*

Fax:

Phone:

Fax

Phone:

Fax;

Customer Survey - Please Complete

How did you hear about Naughton Energy?*

Are you human?*

This field should be left blank