CLARENCE OCHS INC.

d.b.a. Ochs Oil Company

Petroleum Distributor

1321 Distribution Way

Vista, CA92081

(760) 599-9572

FAX (760) 599-0417

E-Mail – .

 Corporation ٱ LLC  Sole Proprietorship Government  Partnership

Name ______If Partnership, list ______

Full Name of Each

Doing Business As ______Member of Firm, If ______

Corporation, list Names

Street or PO Box (Business)______of Principal Officers/______

Directors/ Stockholders

City ______State _____ Zip ______

Accounts Payable Contact: ______Purchasing Agent: ______

Tel No. ( ) _____- ______E-Mail ______

Fax No. ( ) _____- ______

How Many Employees? ______At present location since (year): ______

How Many Years in Business? ______Own land/building at present location? ______

Dunn and Bradstreet # ______

Contractor’s License Number: ______Type of License: ______

Account is a :  Division  Subsidiary

Give Billing Address if different from above addressOf: ______

Parent Company

Street or PO Box (Business)______

(Street orPO Box No.)

City ______State _____ Zip ______City______State______Zip ______

Federal EIN or Social Security # ______

Have you ever filed for Bankruptcy: ٱ No ٱ Yes What Chapter: ______Date of Filing: ______

ESTIMATED MONTHLY CREDIT PURCHASES:BANKING REFERENCES:

IN GALLONS(Attach Additional Sheet if Necessary)

Gasoline: ______Name of Banks Checking # ______

Diesel: ______ Loan #______

Lubricants: ______ Checking #______

 Loan #______

Initial: ______

List Current Trade References and their Complete Addresses  (No Credit Card Accounts Please)

MUST LIST 3…

Name:References: City—State—ZipPhoneFax

REQUESTED INFORMATION:

  1. PAYMENT In consideration of your extending credit to the above named company we agree to pay for any credit purchases under the following terms and conditions: On purchase of full truck and trailer quantities payment shall be made in full for such purchase within ten (10) days of delivery; on all other purchases payment shall be made in full the following 15th of each month of purchase.
  1. PURCHASE ORDERS The terms and conditions of Purchase Orders and/or other similar documents submitted by the Customer to CLARENCE OCHS INC. will not become part of any agreement with CLARENCE OCHS INC. unless accepted in writing.
  1. INTEREST/COSTS Customer understands and agrees that CLARENCE OCHS INC. does not intend to extend credit to Customer other than detailed in paragraph 1 above. Payment is to be made on the due date as specified therein. However, in addition to all other rights should Customer fail to pay when due, interest shall accrue at the rate of one and a half percent (1.5%) per month on the unpaid balance until such time as the indebtedness is liquidated. Further, Customer agrees to indemnify CLARENCE OCHS INC. for all attorneys’ fees, court costs and other legal expenses incurred in collecting any indebtedness owed by Customer to CLARENCE OCHS INC.
  1. RELEASE OF INFORMATION Appraisal of credit responsibility is partially judged on information given on this form. It is therefore important that all information provided and any other additional facts that you may wish to add are provided for a proper credit analysis. Customer agrees that by signing this form it authorizes CLARENCE OCHS INC. to contact all of the above listed banks and credit references for required credit information and such banks and credit references are authorized and permitted by you to release such information.

Date: ______Signed: ______

Title: ______