LYKINS ENERGY SOLUTIONS FLEET FUEL CARD CREDIT APPLICATION

Fleet Fueling Card

APPLICANT INFORMATION
In this Application, "Applicant" means the business entity applying for credit with Lykins Energy Solutions.
Legal Name of Business:*
Tax ID:*
Fictitious Name of Business (DBA):*
County, State Name Registered:*
Billing Address:*
City:*
State:*
Zip:*
County:*
Primary Contact Person:*
Title:*
Office Phone:*
Mobile:*
Fax:*
Email:*
Type of Organization:*
State of Formation:*
Years in Business:*
Type of Business:*
Applicant prefers its invoice to be delivered by:*
Size of Fleet:*
Estimated Monthly Gallons:*
Estimated Fleet Cards:*
Current fleet fuel provider:*
Have you ever declared bankruptcy?*
If Yes: Year:
State:
BUSINESS INFORMATION
*****Attach additional sheets if necessary.*****
Are you a current customer? *
Does your business use any of these products? *
How did you hear about Lykins Energy Solutions?
Check all That Apply *
#1
Name of Owner(s) / Officer(s) #1*
Title #1*
Address, City, State, Zip #1*
Phone #1*
#2
Name of Owner(s) / Officer(s) #2
Title #2
Address, City, State, Zip #2
Phone #2
#3
Name of Owner(s) / Officer(s) #3
Title #3
Address, City, State, Zip #3
Phone #3
Trade Credit References
#1
Name #1*
City, State #1*
Phone #1*
Fax #1*
#2
Name #2
City, State #2
Phone #2
Fax #2
#3
Name #3
City, State #3
Phone #3
Fax #3
AUTHORIZATION AND EXECUTION
By completing this Application, Applicant acknowledges and agrees to have read In full our Credit Disclosure and agrees to comply with the Terms and Conditions set forth herein.
Name:
Title:*
Signature: X*
Date:
9/19/2019
*****Lykins Energy Solutions reserves the right to request additional information in completing its credit review of the Applicant!*****
PERSONAL GUARANTY
For valuable consideration and to induce Lykins Energy Solutions to extend credit to Applicant, the undersigned Guarantor agrees: (1) to unconditionally guaranty Applicant's payment and performance of the Agreement (see reverse), including payment of all present and future debts owed to Lykins Energy Solutions by Applicant; (2) to waive notice of demands and notices of non-payment; (3) that the obligations of this Guaranty are joint and several and are independent from Applicants obligations; (4) to waive all subrogation and recovery rights; (5) to pay attorneys' fees and costs incurred in enforcing this Guaranty; (6) that this Guaranty is binding upon his/her heirs and successors; (7) that his/her bankruptcy shall not affect his/her obligations to repay Lykins Energy Solutions; (8) that this Guaranty is deemed continuing and irrevocable; and (9) that Lykins Energy Solutions is authorized to obtain credit reports on the Guarantor and use said information in the evaluation in the credit of Applicant and authorizes Lykins Energy Solutions to run additional credit reports on Guarantor as may be needed from time to time in their credit evaluation and review process; and (10) to waive any right or claim under the Fair Credit Reporting Act in the absence of this continuing consent.
#1
Name #1*
Title #1*
Signature #1*
Date #1*
#2
Name #2
Title #2
Signature #2
Date #2