Customer Questionnaire - Melzer's Fuel Service

"*" indicates required fields

Company Name / Customer Name:*

Company Owner:*

Company FEIN#*

Company Phone:*

Company Email:*

Company Address:*

Street Address City State ZIP Code

Accounts Payable Contact:*

Accounts Payable Phone:*

Accounts Payable Email:*

Billing Method (Please Select One):*

Mail to Billing Address

Billing Email:*

Taxable*

Yes

Please Upload Your Completed Tax Exempt Form:*

Accepted file types: pdf, Max. file size: 2 MB.

Please Select One Payment Method:*

ACH

EFT

Check

Credit Card

Credit Limit Requested:*

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Submitted By:

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Date Received

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Approved Credit Limit

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Approved Terms:

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Customer Class:

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Approved for Set-Up By (Print Name):

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Sign Your Name:

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Title:

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Additional Comments: