PO Box 510·Marysville·CA·95901 | info@lakeviewpetro.wpengine.com | Phone: (530) 742-7614 | Fax: (530) 742-2328 "*" indicates required fields Step 1 of 6 - Firm Address 16% Firm AddressFull Name of Firm Telephone*FaxEmail Website Mailing Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Home Office Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Company InfoCheck Appropriate Box and provide Information RequestedBusiness Structure Single Entity Subsidiary of (Parent Co.) Corporation Partnership Parent Company Name Mailing Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Federal ID # How Many Years In Business?Type of Business PhoneNames and Addresses of Corporate OfficersNameTitleAddress Add Remove Personal InformationOwner or Manager Name Title Driver's License # License StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificSpouse's Name (If Applicable) Social Security Number Date Of Birth MM slash DD slash YYYY Ever Filed Bankruptcy? Yes No If So, When? Home Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip How Long At The Address Above? Home Status Own The Home Buying The Home Renting The Home Home Phone Cell Phone Fax Previous Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip How Long At The Address Above? Name and Address of Nearest Relative Not Living With YouNameAddressPhone ReferencesBank Name and Branch Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Name of Bank Officer Phone Current Petroleum Supplier(s)NameAddressPhone Add RemoveApproximate Monthly Fuel BudgetNumber of VehiclesNumber of Drivers Agreement & GuarantyI have made the above statements for the purpose of obtaining credit for products and services provided by Lakeview Energy Services. I certify that they are true and authorize Lakeview Energy Services to make a credit investigation. Billings shall be issued twice each month and payments shall be made in full at Marysville, CA within 10 days of the invoice date or by an authorized agreement for direct payments when due. I agree to pay a late charge of 2% per month (24% per year) or $25.00 minimum on any delinquent balances. This agreement includes terms and conditions on the reverse side of this APPLICATION. Facsimile and electronic signatures shall have the same force and effect as original signature. A service charge of $35.00 will be charged for any item returned un-paid. Notwithstanding that this account is established in the name of the company or person listed above, I personally guarantee payment of this account.Name SignatureDate MM slash DD slash YYYY Partner Spouse Name SignatureDate MM slash DD slash YYYY Additional Terms For Products and ServicesPurchases will be for vehicles owned and operated by the Purchaser. Purchaser shall be responsible for all the Purchases by the Purchaser or any other person using CARDLOCK cards issued to the Purchaser and any other NON-CARDLOCK products and services regardless of whether use by any other person(s) is authorized or fraudulent. If there is any change in the ownership of Purchaser or if substantially all of the assets of Purchaser are sold, Purchaser shall promptly notify Lakeview Energy Services (hereinafter referred as "Supplier") of such sale and Supplier shall have a lien on all the assets of Purchaser and a lien of the proceeds of such sale to secure payment of all outstanding sums owing to Supplier. Purchaser represents that it and any person using CARDLOCK cards delivered to purchaser are and shall be aware of the proper use of the CARDLOCK system and shall use safe practices in compliance with the regulations of local Fire Code in the handling of fuels dispensed from the CARDLOCK system. Purchaser agrees to indemnify and hold Supplier harmless from any claims and costs including, but not limited to, those for bodily injury and property damage which may be occasioned by negligence or misuse of the CARDLOCK system by any manner whatsoever. Purchaser agrees that it and any person using the CARDLOCK cards delivered to the Purchaser shall promptly notify Supplier of any malfunctioning of the CARDLOCK system of which Purchaser or such person is aware. Supplier shall use its best efforts to maintain the CARDLOCK system in good working order and condition at its expense, provided however, Supplier shall not be responsible for any damage or loss which may result from its failure to provide fuel or the failure of the CARDLOCK system in any manner whatsoever. Purchaser will be responsible for the clean-up on any and all fuel spills and any damaged equipment repairs caused by Purchaser or any person using CARDLOCK cards delivered to Purchaser. It will be the responsibility of the Purchaser to report any such spill or damage to Supplier immediately and contain said spill with absorbent material furnished at the site. Purchases right to purchase fuel through the CARDLOCK system may be terminated immediately upon any breach of any of the terms hereof or of any other agreement with Supplier and may be terminated without cause upon 30 days’ notice to Purchaser. Upon termination, Purchaser agrees to immediately surrender all CARDLOCK card(s) issued to Purchaser and to immediately pay all outstanding sums to Supplier. In the event of a breach of any of the terms of this agreement or any other agreement between Purchaser and Supplier, including but expressly not limited to the failure to pay sums owing to Supplier when due, then in addition to any other sums due or payable to Supplier by Purchaser, Purchaser agrees to pay all reasonable attorney fees and costs incurred by Supplier in the enforcement of Supplier's rights whether or not a suit or action is filed, in addition to all other sums provided by law. Purchaser further agrees to pay all reasonable attorney's fees and costs incurred by Supplier in connection with the collection of any judgment rendered by a Court of Law in favor of Supplier and against Purchaser. In the event court proceeding are filed to enforce Supplier's rights hereunder, Supplier may choose venue in Sutter County or Yuba County, or other appropriate County. Purchaser agrees and warrants that it shall not allow the PIN numbers to be stored with or on the fuel cards provided by Supplier. Purchaser shall be responsible for all purchases made using CARDLOCK cards delivered to Purchaser. In the event a card(s) are lost or stolen, Purchaser shall be responsible for all purchases made on said card(s) for up to 24 hours from the time Purchaser notifies Supplier of Lost or Stolen card(s) in writing, via facsimile or by hand delivery. All payments will be applied to late charges (if any) then to the oldest outstanding balance. All terms and conditions of this Agreement and Guaranty are intended to cover Purchaser's account as well as all of Purchaser's branch accounts whether set up now or in the future.Person To Contact Regarding Arrangements For Ordering Cards Title Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Phone Extension Are You A Current Pacific Pride User? Yes No Fuel Types Gasoline Diesel Is the Diesel Used For Off-Highway Use? Yes* No * If YES Please read and acknowledge receipt of the following notification regarding RED DIESEL approved use: Red Diesel is for off-road use only. RED DIESEL cannot be used in any vehicle, truck, or tractor that is driven on road. If you are found to be operating a vehicle, truck, or tractor on road with RED DIESEL in the fuel tank, you can incur a very substantial fine. By signing and dating below you acknowledge you have read and understand the proper use of RED DIESEL fuel.Name SignatureDate MM slash DD slash YYYY Payment OptionsAuthorization For Electronic Funds Transfer Customer SignatureTitle Δ