Commercial Credit Application

Business Name:*

Fed EIN #:*

Street Address:*

City*

State:*

Zip:*

Phone #:*

Fax #:

Email:*

Type of Business:*

Years in Business:*

Sales Tax Exempt*

Yes

No

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

Sales Tax Exemption #

Purchase Order Required?*

Yes

No

Accounts Payable Contact*

Bills Paid By:*

Invoice

Statement

Title*

Phone #*

Ext.

Principal’s Name*

Pay by ACH?*

Yes

No

If yes, we’ll send you our banking information

Residence Address*

City*

State*

Zip*

Bank References

Bank Name*

Checking Acct #*

Bank Address*

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:*

Phone:*

Address:*

Fax:

Name:

Phone:

Address:

Fax

Name:

Phone:

Address:

Fax;

Customer Survey - Please Complete

How did you hear about Naughton Energy?*