Thiessen Oil Company
815 Snake River Avenue - Lewiston, ID 83501  Phone: 208-743-6201- Fax: 208-746-8466

Request a New THIESSEN OIL COMPANY Account

Yes, sign me up for Pacific Pride's Automated Fueling with Thiessen Oil Company

For more information about cardlock fueling with Thiessen Oil Company click here.

To apply for a cardlock account from Thiessen Oil Company, simply fill in ALL of the spaces below and SUBMIT the form. If you would prefer to apply over the phone please call us at:

(208) 743-6201
fax: (208) 746-8466

June 19, 2004

Company
Firm Address
Company Name: Company Email:
Phone + Area Code: Fax + Area Code:
Mailing/Billing Address:
City: State: Zip:
if street address is same as above , leave this blank
Street Address:
City: State: Zip:

Legal Structure

Business Structure:  

If you have selected Subsidiary of Parent Company:

Name of Parent Company:
Parent Address:
City: State: Zip:
If you have selected CORPORATION, LLC OR LLP, what State was it formed in?
How many partners or corporate officers?
Officer/Partner  Name: Title:
Officer/Partner  Name: Title:
Officer/Partner  Name: Title:
Federal Tax I.D. / Business License #(s) or equivalent:
How long have you been in business? Years Months
If in business less than one year, please provide the following for the last five years of employment:
Previous Employer:
 Phone + Area Code:
Address:
City: State: Zip:
Employment Dates (mm/yy): From to
If you have additional history, enter it below; otherwise skip this section.
Previous Employer:
 Phone + Area Code:
Address:
City: State: Zip:
Employment Dates (mm/yy): From to

Owner/Officer

Personal
Owner/Officer Name: Title:
Social Security #: Date of Birth:
Email Address: Spouses Name:
Home Address:
 How long? Own or Rent?
City: State: Zip:
Home Phone + Area Code:
 Drivers License #:
 State:
Previous Address:
 How long? Own or Rent?
City: State: Zip:
Nearest relative not living with you:
Relative Name:
 Relationship to you:
Address:
 Phone + Area Code:
City: State: Zip:
Have you ever filed Bankruptcy?
Where? When?

References

Bank: Branch: Account Type: If other, specify:
City: State:
Name of Bank Officer:
 Account #:
 Phone + Area Code:
Trade Reference
Name: Account #: Phone + Area Code:
Name: Account #: Phone + Area Code:
Current Petroleum Supplier(s):
Address: Phone + Area Code:
City: State: Zip:

Other

Are you presently a Pacific Pride cardholder?
Card Number:
 When did you last use your card:
Estimated monthly usage:  (200 gallons minimum)
Accounts Payable Contact:
 Phone + Area Code:
Person to contact regarding arrangements for cards:
 Phone + Area Code:
 Cell or Pager +Area Code:
 
Additional comments or information: (tax exempt info, special requests)

Terms and Agreement

I have made the above statements for the purpose of obtaining credit. I certify they are true and acknowledge that Thiessen Oil Company is relying on these representations in its decision to extend credit. I authorize you to contact the above references and hereby request the references to provide the information requested on my account.

Payments shall be due in full within ten(10) days of invoice date. I agree to pay a late charge of 1-1/2% per month (18% per year) or 50¢ minimum on any delinquent balances. THIS AGREEMENT INCLUDES THE TERMS AND CONDITIONS BELOW.

Signature: you will need to sign here when you print the application.

Guaranty

I unconditionally guarantee the full and prompt payment when due of the Customer's obligations to Thiessen Oil Company, and authorize the accessing of my personal credit report.

Signature: You will need to sign here when you print the application.

If you have completed ALL of the above please click the "Submit" button below.

When you submit this form, our sales department will immediately receive all the information you have entered. However, we still need an original signature, so a printable application will be created containing the information entered above. Please print the application, sign it, and mail or fax it to:
Thiessen Oil Company
P.O. Box 265
Lewiston, Idaho 83501

(208) 743-6201
Fax:(208) 746-8466

Upon receipt of your application we will contact you to personalize your account regarding the number of cards you need, and the type of card system you'd like to use.

Thank you for your interest in Automated Fueling from Thiessen Oil Company