Residential Application Residential Application SALESPERSON * DIVISION * Name * Address * Address Address Address City City State State Zip Zip # of Dependents: * Your Age: * Home Phone : * Work Phone: * Employment & Position: * Years with Employer: * Monthly Income: * Request Joint Account: * Yes No Credit Limit Requested: * Spouse’s Name: * Spouse’s Employment & Position: * Years with Employer: * Work Phone: Monthly Income: HOUSING STATUS Ownership * Own Rent With Parents Type * House Apartment Mobile Home Monthly Housing Payments: * If Renting, From Whom?: * 30 DAY CHARGE ACCOUNTS Account * Phone * plus1 Add minus1 Remove List Previous Supplier: * OTHER INFO Give Name, Address, & Phone # of Relative not living with you: * In the last 10 years, have there been any collections, judgments, garnishments or bankruptcies filed against you or any applicant? * Yes No If yes, explain: * * I (We) warrant that the information provided on this application is, to the best of my (our) knowledge, true, correct, and complete. The additional information provided is also a complete and accurate presentation and may be relied upon by Scott Petroleum in their decision making process. You can read Terms And Conditions * I accept the Terms A Scott Petroleum representative will reach out for additional sensitive data to complete the application. Submit If you are human, leave this field blank.
