To apply for Pacific Pride's Automated Fueling with
Deiter Bros., either complete this online form and click the Submit button or
download the Business Credit Application
and mail or fax it back to us.
The red * indicates required fields.
I have made the above statements for the purpose of obtaining credit.
I certify they are true and authorize you to make a credit investigation.
Billings shall be issued twice each month and will be due in full within
15 days of invoice date. All purchases made on this account will be for
commercial use. I hereby consent to receive communications sent by or on
behalf of Deiter Bros. and affiliates via email or fax, with no date of
THIS AGREEMENT INCLUDES THE TERMS AND CONDITIONS,
AND BY MY CHECKING THE FOLLOWING BOX I ACKNOWLEDGE THAT I HAVE READ THOSE TERMS AND WILL
ADHERE TO THEM.
The undersigned hereby consent(s) to Deiter Bros. use of a nonbusiness
consumer credit report for the undersigned in order to further evaluate
the credit worthiness as principal(s), proprietor(s), and/or guarantor(s)
in connection with the extension of business credit as contemplated by
this Credit Application.
The undersigned hereby authorizes Deiter Bros. to utilize a consumer credit
report for the undersigned from time to time in connection with the extension
or continuation of the business credit accommodation contemplated by this
The undersigned as (an) individual(s) hereby knowingly consent(s) to the use
of such credit report consistent with the Federal Fair Credit Reporting Act
in 15 U.S.C. @ 1681 et. seq.
Please fill in your name and date and CHECK the box to the right to
signify you are the Guarantor.
All state and federal taxes are included in billing unless proper
documentation is on file with Deiter Bros. for states which allow
I want state tax exemption and will provide tax exemption documentation.
State(s) eligible for tax exemption:
I do not want state tax exemption and will pay all taxes at pump.