Please review our Privacy Policy before continuing. Bill To Information: Company Name / DBA* Billing Address* City* State* ZIP* Phone #* E-mail* P.O. Required Yes No Special Forms Required when Submitting Invoices Yes No Form Upload (Required if above question is 'Yes') Upload Preferred Payment Method Check by Mail COD Wire Transfer Credit Card Petro West sends invoices via email. Indicate another method if required Email US Mail Federal ID #* Tax Exempt Yes No Tax Exempt ID # Tax Exempt Certificate (Required if above question is 'Yes') Upload Form of Organization Sole Proprietorship LLC Corporation State Incorporated (if applicable) Principal Owner(s) or Officer(s): Name* Title* Address* Phone #* Name Title Address Phone # Accounts Payable Contact Name* Accounts Payable Email* Accounts Payable Phone #* Site Information: Store / Site Name:* Store / Site Address (if different from billing address) City State County ZIP Phone # E-mail Trade References (Please DO NOT include beverage companies) Name* Address* Phone #* Name* Address* Phone #* Name Address Phone # Do you own or rent the property? Own Rent If you rent, please provide property owner information Property Owner Name Property Owner Address Property Owner City Property Owner State Property Owner ZIP Property Owner Phone # Property Owner E-mail In consideration of the extension of credit by Petro West, Inc., the undersigned purchaser hereby agrees that the terms and conditions of all sales are as follows: I/We authorize any government agency, be it federal, state, or local for the trade references listed above to furnish information to Petro West, Inc. I certify that the above information is true, correct, and complete and hereby give Petro West, Inc. authorization to contact the above trade references for credit information as necessary. * Agree NOTICE: DO NOT SIGN THIS AGREEMENT UNTIL YOU HAVE READ AND FULLY UNDERSTOOD THE TERMS AND CONDITIONS THEREOF.PLEASE TYPE YOUR NAME IN THE BOX BELOW AS YOUR SIGNATURE. BY SIGNING THIS FORM, YOU AFFIRM THAT YOU ARE AUTHORIZED TO DO SO. Company / Corporation Name* Signature (President/Partner/Owner) [type name]* Title* Date* Submit
