Residential Fuel Card Application

Online

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
Name*
First Middle Last Suffix
Primary Phone*
Is this a home phone or cell phone?*
Secondary Phone*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Is this your physical address?*
Physical Address
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Are you or your spouse active or retired military?
Email*
Employer Name*
Employer Address*
Street Address Address Line 2 City State ZIP Code
Employer Phone*
Employer Website
Years Employed*
Nearest Relative Not Living With You
First Last
Relative's Address
Street Address Address Line 2 City State ZIP Code
Relative's Phone
Do You Own or Rent Your Home?*
Landlord's Name
First Last
Landlord's Phone

Co-Applicant
Do You Have a Co-Applicant?*
Co-Applicant's Name
First Middle Last Suffix
Co-Applicant's Primary Phone
Co-Applicant's Secondary Phone
Co-Applicant's Mailing Address
Street Address Address Line 2 City State ZIP Code
Is This the Physical Address?
Co-Applicant's Physical Address
Street Address Address Line 2 City State ZIP Code
Co-Applicant's Date of Birth
MM slash DD slash YYYY
Co-Applicant's Email
Co-Applicant's Employer
Co-Applicant's Employer Address
Street Address Address Line 2 City State
Co-Applicant's Employer Phone
Co-Applicant's Employer Website
Co-Applicant's Years Employed
Name of Co-Applicant's Nearest Relative Not Living With Them
First Last
Co-Applicant's Relative Address
Street Address Address Line 2 City State ZIP Code
Co-Applicant's Relative Phone
Does Co-Applicant Own or Rent Their Home
Co-Applicant's Landlord Name
First Last
Co-Applicant's Landlord Phone

Fuel Cards
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?
NOTICE TO APPLICANT
NOTICE TO APPLICANT: Credit terms are Prox. 20. All charges made in a given month are due and payable in full by the 20th of the following month. I/We hereby authorize Holtzman Oil Corp. to obtain information from my bank required to approve credit as listed on this application. I/We authorize Holtzman Oil Corp. to make inquiries considered necessary (including requisition 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 the County of Shenandoah, State of 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 and Below Notice*
- Yes
Click here to read the Fuel Card agreement

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I Have Read and Understand the Fuel Card Agreement*
- Yes
Applicant's Signature*
Use your mouse, or a stylus or finger on mobile devices.
Co-Applicant's Signature

Residential Fuel Card Application

Online

Step 1 of 3

Applicant Information

Co-Applicant

Fuel Cards

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