Commercial Credit Application Application - Commercial Credit Step 1 of 8 12% NameThis field is for validation purposes and should be left unchanged.In order to establish an account with Valley Energy, you must fill out the form below to apply for an account. You will receive an email confirmation at the email address you provide and the Valley Energy Customer Service staff will contact you shortly. The following information is for the purpose of obtaining credit history and will be kept strictly confidential. Business InformationFirm Name*Type of Business*Date Established Owner/Partner/Officer Name* First Last Title*Second Owner/Partner/Officer Name First Last TitlePrimary Business Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this the mailing address?* Yes No Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Business Phone*Phone Type* Mobile Office Additional PhoneAdditional Phone Type Mobile Office Email* Business Fax Fuel Type* Propane On-Road Diesel Off-Road Diesel Heating Oil Gasoline Commercial Fueling Station Other If you chose "other", please explain.Previous Fuel Company Name The information submitted is for the purpose of obtaining credit history and will be kept strictly confidential. Has the applicant or any of its owners, principals, partners, officers, or directors ever filed a voluntary petition in bankruptcy, been adjudged bankrupt, or made an assignment for the benefit of creditors?* Yes No If you answered yes to the question above, please explain.* Accounts PayableAccounts Payable Contact Name First Last Accounts Payable EmailAccounts Payable Phone Number Text Message Notifications:*AgreeOpt Out Of Text MessagesBy checking “agree,” you agree to receive billing receipts, promotional messages and delivery/service status updates sent via text message to all mobile phone numbers. Message frequency varies. Message and data rates may apply. How did you hear about us?* Facebook Instagram Internet Search Postcard Friend/Neighbor Saw a Valley Energy Truck At A Valley Energy Sponsored Event Credit Policy Terms and Credit Agreement Payments are due upon receipt of invoice. A LATE CHARGE may be assessed on all balances over thirty (30) days. This is computed by a periodic rate of 2% (which is an annual percentage rate of 24%) on the portion of the previous balance over thirty (30) days less payments and credits appearing on the statement, plus $50 per month late fee. An account is considered past due when a LATE PAYMENT CHARGE is assessed. Any account which becomes past due is subject to termination of automatic fuel delivery WITHOUT NOTICE until the account balance is paid in full. All fuel remains the property of Valley Energy until paid in full. Valley Energy reserves the right to reclaim ANY FUEL not paid in full. Should past due account(s) require the assistance of a collection agency and/or attorney to obtain payment(s), the credit applicant herein agrees to pay all costs, including any attorney’s fees (40% of outstanding principal balance), associated with collection and any subsequent enforcement action. The applicant also agrees that Virginia law shall apply, and litigation must be filed in the Courts of Loudoun County, Virginia.. A service charge of $35.00 will be added on any check or eCheck returned by a bank. I certify that the information contained in this document is true and accurate and is submitted to Valley Energy in conjunction with a request for credit. References listed are authorized to release any credit information to Valley Energy. A copy of this authorization shall be as valid as the original. Company Name*Full Name* First Last Title Signature*Your NameYour NameYour NameYour Name Personal Guaranty In consideration for the extension of credit for the purchase of goods or services to the applicant, THE UNDERSIGNED PERSONALLY GUARANTEES THE UNCONDITIONAL PAYMENT OF ANY UNPAID AMOUNT UPON APPLICANT’S ACCOUNT. This is a guarantee of payment and not merely of collection; no collection or civil action need be commenced against the Applicant prior to a demand being made upon the undersigned. A copy of this guarantee shall be as valid as the original. Guarantor Full Name First Last Title Guarantor SignatureYour NameYour NameYour NameYour NamePersonal Gauranty Opt Out Request I request to opt out of signing the Personal Gauranty. I recognize by not signing the personal guarantee, it may impact my eligibility for credit approval from Valley Energy.* Agree Second Guarantor Full Name First Last Title Second Guarantor SignatureYour NameYour NameYour NameYour Name Credit Investigation Authorization I hereby authorize Valley Energy to make whatever credit investigation they may deem appropriate and to exchange any information they may receive in the course of such investigations. A comply of this authorization shall be as valid as the original Guarantor Full Name First Last Title Guarantor SignatureYour NameYour NameYour NameYour NameCAPTCHA
