Application for Credit

To apply for credit please fill in the following and click submit.

Please select which location you would like to open a credit account with:
Nebraska Iowa Supply Co.	Petro Mart I Blair, NE	Petro Mart II Blair, NE	Petro Mart Omaha Omaha, NE


Company Name

Service Address	City	State	Zip Code
Phone Number	Fax Number

Billing Address	City	State	Zip Code
Phone Number	Fax Number

Nature of Business
Type of Business	Corporation	Partnership	Sole Prioprietorship
Federal ID Number	Years in Business
Anticipated Credit Limit	Resale Tax Number

List All Owners, Officers or General Partners
Name	Title	Social Security Number
Address	City	State	Zip Code
Phone Number

Name	Title	Social Security Number
Address	City	State	Zip Code
Phone Number

Name	Title	Social Security Number
Address	City	State	Zip Code
Phone Number

Bank Reference
Name of Bank	Bank Contact
Account Number	Type of Account
Address	City	State	Zip Code
Phone Number

Current Trade References
Name	Account Number
Address	City	State	Zip Code
Phone Number

Name	Account Number
Address	City	State	Zip Code
Phone Number

Name	Account Number
Address	City	State	Zip Code
Phone Number

Please click submit to apply for credit
By submitting, I(We) certify that all the information on this form is correct. I(We) authorize Nebraska Iowa Supply Co., or it's subsidiaries to perform a credit evaluation on the Company and/or the Owner(s) of the Company in connection with this Application for Credit. I(We) fully understand your credit terms and agree to the proper payment for consideration of extended credit.