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01, <br /> Lubricants LL <br /> 1828 W. Cpllins Ave., orange, CA 92$633765• p07 Box 5786, Orange, l'A 92883-5785 • (800) 004.6023 • FAX (714) 522-7313 • www.sclubrkenit, trsm <br /> 7984 Daggef Street, San Dlepo, CA 92111 • (859) 277.3822 • FAX (668) 277- 1361 992 Hensley 31rer1, Richmond, CA 94901 • (804) aoe.58p,3 • FAX ( 275 -0194 <br /> Sotdhem Counties oil Go, • Fleet Puela • TOM Encray Products • Cardlook Fuels System • SC Fuels • www.sofuelstw ri <br /> C 1 o I Rq 1001 • <br /> This will give authorization 9 raw <br /> to any information nepeSsa toward proregstrrrt of an account a liastlon with ono or more Of southern Counties Lubrl <br /> Southam Coiantiaa Oil Cp, Ltd G lock Fuels SA� 21ystem Ino„ Fueis, ji1v information will pP carte, LLC, <br /> bo kept strictly cUnfidantial. <br /> LAJ Signature <br /> Le at m ' � � Date Of Application <br /> 9 �§ e of Com y <br /> MA <br /> Telep one# - - Parsr� a; E Ma,t <br /> AV <br /> Main BUSIne�ss��.ppOtivlty ,�ve,x_z I�,tUSiness Resale Ertl U9ar SIC Code <br /> Company's t;u entAddresg — City F AW Zip <br /> a ` Howe 0%fit This Address? <br /> 818Ing Addresv, If Different City State L .tn 1 ~S <br /> Zip t9laphane <br /> Have you ever filed for Corporate Bankruptcy? ❑yes No 1 If so, when and what Chapter? <br /> Check ono of the fbtlowing: <br /> ❑ Proprietorship I�—yy partnership LI, <br /> Ll R ❑ O ❑ CorlaprdiOn ❑ Non Profit Federal ID9 <br /> Pn ry 8amk Address City <br /> state <br /> zfp <br /> Sank on Pmraon/Phnnp# Fax# <br /> Account Type Number. <br /> moo ary an <br /> fe99 <br /> e _ P <br /> Bank Contact Petson/Pho Fax# <br /> Aca+Unt Type d NU C <br /> SUSinass Name <br /> Address city Sfate P <br /> hone# Fes} <br /> BU31nes5 Name Address <br /> Coy tate Phone# Faxtt <br /> Business Name Add s <br /> Cay State Phone# Fsx# <br /> N 10 1M A <br /> Name Poo <br /> Home Address -y- <br /> City/St. 7J Cada <br /> Homo Phare - - R - <br /> frtrivofso LIC. Of Birth <br /> PteviousAddro55 <br /> — � _ <br /> Personal Not Worth —` r <br /> _ Have y ever bh)d for Pe net Bankruptcy? <br /> If $0, when and what chapter? <br /> I ct3rti(y tht I SM the person named shove and that the foregoing is t and correct. As a principal of <br /> I authorize and Mqu The Gompanles to consider my personal c _ in CptljUnction with this application for my <br /> ctompany's account. <br /> [XI <br /> Name Signature <br /> Home Addro55 Position <br /> --- �t <br /> City/St. —_.. . tip e .- <br /> Home Phone <br /> Date of 131rtl7 <br /> Pn9vioue Addit Driver's Lic. 4 s <br /> Personal NetWor(h Havt, You cVer filed for Persanai Banlcru • r. " <br /> If 80, whom and what chapter? pt Y7 -" <br /> I cOrtlfy tht I am the person n9 d shove and that the forrs(oing is true and corrcct. As a principal of <br /> 1 authorize ane request The GOMPantes to consider my personal credit In conjunction with this application for my <br /> company's account. r <br /> IXl <br /> Signature <br />