Mailing Address: P.O. Box 3127, Brockton, MA 02304

Gas Station Credit Application Page

Gas Station Credit Application

    Vehicles:

    Make Year Type Plate # Fuel Type

    Authorized Signatures:

    Credit References:

    Terms: Due in full on the 15th of the following month

    Payment options:

    To apply for credit, provide a copy of your MA Drivers License or Identification Card

    First delivery is prepaid with cash or credit card.

    Future deliveries will be extended credit equalling the amount paid for with the first delivery.

    Future deliveries must be paid within ten days to retain earned credit.

    Accounts not paid within 30 days will be forwarded to a collection agency.

    OR Provide credit or debit card to be kept on file to be automatically processed for each delivery

    OR Pay cash to the driver upon delivery

    OR Become a budget customer! (See separate page for information)

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