Please read the following before completing this form:

1. Applicant represents that the information given in this application is complete and accurate and authorizes Walsma Oil Co. to check with credit reporting agencies, credit references and other sources disclosed to confirm information given.
2. Applicant requests a commercial/personal charge account if approved for credit.
3. Please note that a signed credit application must be received prior to receipt of product.

NOTE: You may print this application, complete, sign and fax to: 
Walsma Oil Company at 1-(661) 723-0116
Please mail original signed application to:
44141 N. Yucca Avenue
P.O. BOX 17
Lancaster, CA 93534
This process will speed up processing and be far more confidential than email.

If you have any questions regarding the completion of this application, please call (661) 945-4772 or (661) 942-3637

Commercial AccountPersonal Account

Full Legal Name: Title:
OR
Business Name: DBA:
Subsidiary of:
Address:
City: State: Zip
Phone: Fax:
email:
Date of Birth: Soc. Sec. #:
Current Sellers Petroleum customer? NO YES, #
References:

Name: Contact:
Phone: Fax:
Name: Contact:
Phone: Fax:

Please review your application before submitting.