Credit Application

PLEASE complete this application in full. Applications submitted incomplete shall not be approved.

Name

Address 1

Address 2

City

State

Zip Code

Telephone Number

Email Address

Social Security Number *(not required)

CREDIT REFERENCES - PLEASE LIST THREE (BANK OR CREDIT CARD)

First Reference Name

Address

Telephone Number

Second Reference Name

Address

Telephone Number

Third Reference Name

Address

Telephone Number

Current Employer

Position

If less than one year, name of previous employer

I agree that: (1) Country Oil has my express consent to conduct an investigation about my credit background and (2) the approval of this application is subject to the results of such an investigation. A surcharge of $.10 per gallon is charged if the account is not paid within ten (10) days of date of delivery. Any amount not paid within 30 days will be charged 1 1/2% per month plus surcharge. No further deliveries will be made until previous delivery is paid in full. By submitting this form you agree to the terms disclosed. **YOU WILL BE NOTIFIED IF CREDIT DOES NOT APPLY.

Country Oil Inc., 540 Northfield Road, Bernardston, MA 01337

Credit Application

CREDIT REFERENCES - PLEASE LIST THREE (BANK OR CREDIT CARD)

Country Oil Inc., 540 Northfield Road, Bernardston, MA 01337

1-800-327-9992