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Bill To Information:
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Principal Owner(s) or Officer(s):
Site Information:
Trade References (Please DO NOT include beverage companies)
If you rent, please provide property owner information
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.
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.

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