Company Contact Information:

 

 

Company Name:

 

Authorized Signatory:

 

Address:

 

 

 

 

 

Telephone:

 

E-Mail:

 

 

Company Logistics Information:

 

 

I.R.S. 637(S) Identification Number:

(Please provide copy of IRS 637(S) Letter Issued)

 

Purchase Type: (Spot or Contract)

 

Payment Description:

 

Type of Fuel Description:

 

Number of Gallons Per Shipment:

 

Desired Fuel Movement: (wkly/mthly)

 

Fuel Point of Delivery:

 

Transportation Type:

(Pipeline, Rail, Vessel or Barge provide full description)

 

Shipping Company:

 

Customer Service Representative:

 

Address:

 

 

 

 

Charter Party:(If applicable) (Y/N)

 

Name of Pipeline:

 

Pipeline Shipper’s Code:

 

Pipeline Confirmed Cycle Number:

 

Storage Terminal Name:

 

Terminal Service Representative:

 

Address:

 

Customer I.D. Number:

 

 

 

 

BUYER’S Commercial Banking:

 

 

Bank Name:         

 

Address:

 

 

 

Bank Officer’s Name:

 

Telephone | Facsimile:

 

Secured E-Mail:

 

Account Name:

 

Account Number:

 

A.C.H. Routing Number:

 

S.W.I.F.T. Code: