| Westex
Capital Ltd. Pico
Petroleum Products Pico
Fuel Club Pico
Convenience Stores
Divisions available to serve your needs:
Del Rio, TX 78840-4209 Carrizo
Springs, TX 78834-0709 Kenedy, TX
78119 Boerne,
TX 78006-1289 Uvalde, TX 78802-0508
(830) 776-7581 (830)
876-2527 (830)
583-2421 (830)
249-2416 (830)
278-5681
(830) 776-4956 Fax (830)
876-9578 Fax (830)
683-9578 Fax (210) 698-2106
(830)
249-8598 Fax
The undersigned is applying for extension of
credit. The following information, which
the undersigned warrants to be true and correct, is submitted as a basis for
considering this application. The
Companies, Westex Capital, Ltd., Pico Petroleum Products, Pico Fuel Club, Pico
Convenience Stores, (hereinafter the “Companies”) are authorized to investigate
relationships with trade suppliers or financial institutions for the purpose of
establishing credit.
1.
Legal Business Name _______________________________________________________In
Business Since_______________
d/b/a/
________________________________________________________Fed.I.D. No. Or
SS# ____________________________
2.
Address:
_______________________________________________________________________________________________
Street
City
State Zip
3.
Ship to Address:_________________________________________________________________________________________
Street
City State Zip
4.
Phone
No. ______________________________________________Fax No. ___________________________________
State of
5. We do business as a □ Corporation □
Partnership □
Sole
Partnership
□ Limited Partnership
6.
Full names and home address of all corporate officers
general and limited partners, or proprietor (give social security number if a
Partnership
or Sole Proprietorship):
NAME TITLE ADDRESS SOC. SEC. # DRIVERS LICENSE #
__________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________
7.
Type of Current Business
____________________________________________________________________________________ 8. Has the undersigned filed or been the
subject of a bankruptcy as a company or as an individual? □
Yes
□
No
If Yes, give type of bankruptcy and date
filed
___________________________________________________________________
9.
Credit Limit Requested $
___________________________________________________________ 10. Are
purchase orders required?
□
Yes □
No 11. All orders will be provided on a C.O.D. basis until credit is approved. The undersigned acknowledges that the Companies’
extension and maintenance of credit is at the
Companies’ sole discretion.
12.
Current financial statements are required with this application. Updates are required as requested by
companies.
13.
Major Trade References:
_________________________________________________________________________________________________________
NAME COMPLETE
ADDRESS AVG.
BALANCE _________________________________________________________________________________________________________
PHONE FAX CONTACT
PERSON
_________________________________________________________________________________________________________
NAME COMPLETE
ADDRESS AVG.
BALANCE
_________________________________________________________________________________________________________
PHONE FAX CONTACT
PERSON
_________________________________________________________________________________________________________
NAME COMPLETE
ADDRESS AVG.
BALANCE
_________________________________________________________________________________________________________
PHONE FAX CONTACT
PERSON 14.
Bank References: ___________________________________________________________________________________________
NAME COMPLETE
ADDRESS
_________________________________________________________________________________________________________
PHONE ACCOUNT
NO. & TYPE OF ACCOUNT CONTACT
PERSON
_________________________________________________________________________________________________________
NAME COMPLETE
ADDRESS
_________________________________________________________________________________________________________
PHONE ACCOUNT
NO. & TYPE OF ACCOUNT CONTACT
PERSON
_________________________________________________________________________________________________________
NAME COMPLETE
ADDRESS _________________________________________________________________________________________________________
PHONE ACCOUNT
NO. & TYPE OF ACCOUNT CONTACT
PERSON 15.
The undersigned acknowledge(s) the Companies payment
terms to be: All accounts are due and
payable Net 30 days; and agrees to remit payment in
accordance therewith. Past due accounts shall
bear interest at the rate of 18% per annum compounded monthly. The undersigned
further acknowledge(s) that the foregoing payments terms are subject to change
without notice.
16. The undersigned agrees to notify the Companies of changes in name, address, ownership or legal
entity. 17. The undersigned agrees that in order to induce the Companies to extend credit, the proper venue and situs for any suit to collect
unpaid
amounts shall be in 18.
I further
understand that in consideration of the extension of credit to my company for
purchase of goods or services, in return I am signing this document
and promising to pay in full, in both my individual capacity and on behalf of
my company. I hereby unconditionally guarantee
payment of all amounts of credit extended to the above named company and
individuals from the date hereof. I
further warrant that the
above information is all true, complete and correct. 19.
Submitted
this ___________________________day of ______________________________________,
20____. 20.
_______________________________________________ SIGNATURE
_____________________________________________________ TITLE
COMPANY’S USE
ONLY
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