NEIA MEISINGER PETROMART CREDIT APPLICATION Printable Credit Application Form 1160 Lincoln Street, P.O. Box 368, Blair, NE 68008 ph: 402.426.2171 | mail@neiasupply.com | fax: 402.426.2360 Company Name or Individual Applicant Name * Billing Address Address Line 1 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Phone * Email for Invoicing * Service Address Address Line 1 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Years in Business Type of Entity if Applicable Corporation Sole Proprietorship Partnership N/A Federal ID Number Anticipated Credit Limit Nebraska-Iowa Supply Sales Rep Name Please provide a copy of your latest Balance Sheet and Income Statement to expedite credit requests. Click or drag files to this area to upload. You can upload up to 5 files. **All information is held in strict confidence and used solely for credit evaluation purposes. Ownership List all Owners, Principals, Members, General Partners, or Officers (attach pages if needed). Name First Last Title SSN SSN is required for individuals and sole proprietors applying for credit. Address Address Line 1 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Banking Reference Name of Bank Bank Contact Address Address Line 1 City Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Phone Email Fax Current Business Trade References Company Contact Phone Email Additional Trade References Company Contact Phone Email Additional Trade References Company Contact Phone Email Additional Information Are there any pending judgments/lawsuits against you or a joint applicant? Yes No Have you or a joint applicant declared bankruptcy in the last 14 years? Yes No Do you or a joint applicant have taxes that are delinquent or under dispute? Yes No Are you or a joint applicant contingently liable (as guarantor) on any debts? Yes No Does anyone possess a lien or security interest on your or a joint applicant's property? Yes No If you answered "Yes" to any of these questions, please explain, including names of parties involved and amounts. Upload any additional needed documents Click or drag files to this area to upload. You can upload up to 5 files. Signature * Clear Signature I (We) certify that all the information on this form is correct. I (We) authorize Nebraska Iowa Supply Co., Inc., dba Nisco Energy, it’s subsidiaries, or affiliates to perform a credit evaluation on the Company and/or the Owner(s) of the Company in connection with this Application for Credit, including obtaining consumer credit reports. I (We) fully understand your credit terms and agree to the proper payment, as it is invoiced, for consideration of extended credit. I (We) acknowledge additional fees may apply if invoices are paid by credit card. This Agreement is performable for all purposes in Blair, Washington County, Nebraska Captcha * What is 7+4? Submit © 2020 ALL RIGHTS RESERVED PRIVACY POLICY CONTACT US BLAIR OFFICE | 402-426-2171 OMAHA BULK PLANT | 402-393-8350 mail@neiasupply.com CUSTOMERS Credit Application Safety Data Sheets Nebraska Petroleum Marketers and Convenience Store Association FUEL Iowa Association NAVIGATION Pages ABOUT US CONTACT US CREDIT APPLICATION GRACO MEISINGER Meisinger About Us Meisinger Homepage NEIA HOME PETROMART Privacy Policy PRODUCTS SERVICES