CREDIT APPLICATION

Company Name

DBA (Doing Business As)

Federal Tax ID

State Tax ID

Billing Address (Street, City, State, Zip)

Accounts Payable Contact Name

Shipping Address (Street, City, State, Zip)

Company Phone #

Company Fax #

Preferred Invoice/Statement Method (Fax or Email)

Company Type (Corporation / Partnership / Sole Proprietor)

If Incorporated, State of Incorporation

Type of Business

Owner / Partner / President Name

If Contractor, Bonded? (Yes / No)

How Long Has the Company Been in Business?

Number of Employees

Other Business Names (if any)

Do You Require a Purchase Order? (Yes / No)

Desired Credit Amount ($1,000 / $2,000 / $7,500 / $15,000 / $30,000 / $60,000)

State Tax Exempt? (Yes / No)

Parish/City Tax Exempt? (Yes / No)

Excise Tax Exempt? (Yes / No)

Delivery Point (Inside City Limits / Outside City Limits)

Exemption Number (if exempt — attach exemption certificate)

State Name and Tax %

Parish/County Name and Tax %

City/Town Name and Tax %

Owner 1: Name / Social Security # / Spouse

Owner 1: Address / City & State / Zip Code

Owner 2: Name / Social Security # / Spouse (if applicable)

Owner 2: Address / City & State / Zip Code

D&B: Rated on D&B? (Yes / No). If yes, D&B Number:

Bank: Name / Loan Officer / Account #

Bank: Address / City, State, Zip / Telephone & Fax #

Credit Reference 1: Name / Address / Phone / Fax (at least one must be a prior fuel supplier)

Credit Reference 2: Name / Address / Phone / Fax

Credit Reference 3: Name / Address / Phone / Fax

EFT Account Name (Customer Name)

Financial Institution Name

Financial Institution: City / State / ZIP

ABA Routing Number

Account Number

Customer: Print Name / Title / Date

Guarantor Name / Purchaser Company Name

Guarantor: Print Name / Social Security Number

Guarantor: Home Address / City / State / Zip Code

By entering your name below, you certify that all information is true and correct and agree to Siarc Inc. terms and conditions of credit — Print Name / Title