Commercial Fuel Card Application

Online Submission

Please complete the online application below to start the application process. For your security, a Holtzman Customer Service Representative will contact you to gather additional information, including social security number(s) and bank information.

Step 1 of 3

Applicant Information
Person Completing Application*
First Middle Last
Email*
Legal Business Name*
Business Name
Primary Phone*
Fax
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Business Structure*
In the State of*
State
Date Started*
MM slash DD slash YYYY
Federal Tax ID

If SSN, leave blank
Business License Number*
Tax Exempt?*
Monthly Credit Limit Requested*
Description of Business*
Name of Accounts Payable Contact or Controller*
First Last
Direct Phone*
AP Contact or Controller Email*

Owner, Partner or Officer Information
Owner, Partner or Officer Name*
First Middle Last Suffix
Percent Ownership*
Title*
Owner, Partner or Officer Home Address
Street Address Address Line 2 City State ZIP Code
Owner, Partner or Officer Phone*
Owner, Partner or Officer Cell Phone
Owner, Partner or Officer Email*
Additional Owner, Partner or Officer Name
First Last
Additional Owner, Partner or Officer Percent Ownership
Additional Owner, Partner or Officer Title
Additional Owner, Partner or Officer Home Address
Street Address Address Line 2 City State ZIP Code
Additional Owner, Partner or Officer Phone
Additional Owner, Partner or Officer Cell Phone
Additional Owner, Partner or Officer Email

Fuel Cards & Bank Information
Number of Fuel Cards Requested*
Please enter a number greater than or equal to 1.
Do You Wish to Require a Vehicle Number for Card Use?
Mileage Required?
Bank Name for Business Account*
Bank Address*
Street Address Address Line 2 City State ZIP Code
Bank Phone
NOTICE TO APPLICANT
Credit terms are Net 30 days. All invoices are due in full within 30 days from date of invoice. I/We hereby authorize Holtzman Oil Corp. to obtain information required to approve credit from my bank as listed on this application. I/We authorize Holtzman Oil Corp. to make inquiries considered necessary (including requesting reports from consumer reporting agencies and other sources) in evaluating this application, and subsequently, for purposes of reviewing, maintaining or collecting this account. This contract shall be construed under the laws of the State of Virginia, and the parties agree that jurisdiction and venue in any legal action relating to this contract shall be established, instituted, and prosecuted in the Courts of Shenandoah County, Virginia. To the extent permitted under applicable law, you will be responsible for interest at the rate of 18% per annum on all amounts not paid within terms and for all collection costs including reasonable attorney’s fees, court costs and any other fees necessary for collection of any unpaid balance or for any other legal action relating to this contract.
I Have Read and Understand the Above Notice*
- Yes
Applicant's Signature*
Use your mouse, or a stylus or finger on mobile devices.
Co-Applicant's Signature
PERSONAL GUARANTY: I/we do hereby unconditionally guaranty payment on all accounts opened and approved by this application. This is a continuing guaranty and shall remain in force until revoked by me or us in writing. Each person who signs this guaranty/application can personally be held jointly and severally liable for all amounts owing without suit having been filed first including interest at the rate of 18% per annum on all amounts not paid within terms and for all collection costs including reasonable attorney’s fees, court costs and any other fees necessary for collection of any unpaid balance or any other legal action relating to this contract. I/We hereby authorize Holtzman Oil Corp. to obtain information required to approve credit from my bank as listed on this application. Guarantor(s) consent(s) to the jurisdiction of the courts of Shenandoah County, Virginia, over any action filed against guarantor for the collection of the account. By signing this application, I/We authorize Holtzman Oil Corp. to make inquiries considered necessary (including requesting reports from consumer reporting agencies and other sources) in evaluating this application, and subsequently, for purposes of reviewing, maintaining or collecting this account.
Guarantor Signature*
Guarantor Name
First Middle Last Suffix
Additional Guarantor Signature
Additional Guarantor Name
First Middle Last Suffix

Commercial Fuel Card Application

Online Submission

Step 1 of 3

Applicant Information

Owner, Partner or Officer Information

Fuel Cards & Bank Information

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