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Online Credit Application (Steps: 1-7)
Select this method if you wish to send us a Online Credit Application. Simply fill in all the (*) required fields below and press 'send'. We will take your information and respond as soon as possible.


Note: See optional pdf credit application download below.


1) Personal Information:
Complete Name: *
E-Mail Address: *
Social Security #: *
Number/Dependents: *
Applicant Age: *
Joint Account?: *
If yes, Spouse Name?: *
Credit Limit Requested: *

Applicant Address
Address: *
City: *
State/Province: *
ZIP/Postal Code: *
Phone: *
Fax:

2) Housing Status
Housing Status: *
Housing Type: *
Monthly Housing Payments *
If Renting, Whom?:


3) Bank Accounts:
Name of Bank: *
Bank Address: *
Bank Phone: *
Checking Acct #: *
Savings Acct #: *
LABEL: *
Years with Bank: *


4) Credit References:
Give the contact info of a relative not living with you: *
Name: *
Phone: *
Address: *

30 Day Charge Accounts: (previous supplier)
Name 1: *
Phone: *
Name 2: *
Phone: *
Name 3: *
Phone: *

5) Other Information:
In the last ten (10) years, have there been any collections, judgements, garnishments or bankruptcies filed against you or any applicant?: *
If Yes, Explain:



6) Employer Info
Applicant Employer 1
Name of Employer: *
Address of Employer: *
Monthly Income: *
Position(s) Held: *
Years with Employer: *
Work Phone: *

Spouse Employer 2 (if joint)
Name of Employer: *
Address of Employer: *
Monthly Income: *
Position(s) Held: *
Years with Employer: *
Work Phone: *


7) Authorization:
I certify that the facts contained in this credit application are true and complete to the best of my knowledge and understand that, if approved, falsefied statements on this application shall be grounds for termination.

By sending this, I hereby authorize Scott Petroleum to perform a credit check and verify all statements contained herin and the references and employers listed above and release the company from all liability for any damage that my result form utilization and such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for credit approval for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

Date of Submission: *
Your Virtual Signature: *
Note: Your IP Address Recorded

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(Optional) PDF Credit Application
[ Acrobat PDF ] Note: If you prefer you can download our PDF Credit Application, complete it and snail mail it in.

Simply download the Commercial or Consumer PDF application to begin. Mail it back in here.






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