Name	* required
Address	* required
City	* required
Home Phone	* required
Cell Phone
FAX
Property	Own Leased
Social Security Number	* required
Drivers Licsence or I.D. #	* required
Approximate Credit Amount Desrired?
Financial Information
Name of Bank	* required
Phone Number	* required
Address	* required
Account Number	* required
Credit Card Information
Card Type	Master Card Visa Discover
Card Number (No Spaces)	* required
Name on Card	* required
Expiration Date	* required
Security Code
Your credit card will be used to guarantee your account.   By submitting this credit application, you hereby authorize Van Etten Oil Co. Inc. to have access to all credit information with respect to any financial institution which is listed on this application and hereby also directs such financial institution to comply promptly and fully with any request which is generated from Van Etten Oil Co. Inc. concerning information about those withholdings.
References
Name Address Phone # (List Three References)
Charge Services By:	Purchase Order Phone Order All Methods
THIS IS TO CERTIFY, THAT I PERSONALLY GUARANTEE THIS ACCOUNT. I consent to any further extension of credit and/or acceleration of amounts due or any part thereof or release of any party liable for the payment thereof or any collateral thereto, all without notice and without affecting or releasing the liability of any of us, which is hereby declared to be absolute. I also agree to pay all costs of collection, including disbursements and attorney's fees calculated at the rate of 1/3 of all amounts due, whether or not suit is actually instituted.   By submitting this Credit Application, the undersigned acknowledges familiarity with, and acceptance of, the conditions set forth in this application.   Courts located within the County of Sullivan, State of New York, shall have exclusive jurisdiction of all disputes arising from, or related to, this credit application and/or the underlying obligations.  The choice of Court shall be determined by the monetary amount involved: i.e., the Village Court of the Village of Monticello for claims up to $3,000.00 and the Supreme Court, or the County Court of Sullivan County for claims exceeding $3,000.00.   If any portion of this Agreement is deemed void or unenforceable, it shall not affect the balance of this Application which will be enforced to the fullest extent permitted by law.
	I agree with the terms of this credit application. I disagree with the terms of this credit application.