Stand Energy: Power Services, Natural Gas, Electric Supply, Residential & Commercial customer choice

Legal Business Name:

Email Address

DUNS #

Type:

Corporation

LLC

Sole Proprietorship

Partnership

Other

State Where Business Incorporated/Registered/Chartered:

Year Established:

Type/Description of Business:

SIC Code (if known):

Federal Tax ID No.:

Owners/Officers/Members	Job Title	Percentage Ownership

Key Management Name	Job Title	Direct Telephone/Extension


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Business Address:

State:

Zip Code:

Billing Address:

State:

Zip Code:

How frequently does your company/business pay its suppliers?

Daily	Weekly	Monthly
Bi-Weekly	Bi-Monthly	Semi-Monthly

Other (specify):

Payment Form:

Cash

Check

Wire

Credit Card

ACH

Does your company pay within supplier's invoice terms?

Yes

About Your Company/Business:

Has	Does Not Have
		Currently unsatisfied/unreleased liens of any kind?
		Lawsuits of counterclaims filed by or against in the last 3 years?
		Any currently unsatisfied judgments of any kind?
		Debtor in Chapter 7 or 11 Bankruptcy (Voluntary or Involuntary) at any time in the last seven (7) years?

Bank and Trade References:

Bank

Bank Name:

Address:

Contact:

Telephone Number:

Suppliers

Trader Name:

Address:

Contact:

Telephone Number:

Trader Name:

Address:

Contact:

Telephone Number:

Trader Name:

Address:

Contact:

Telephone Number:

I hereby certify that the above electronic information is true and accurate to the best of my knowledge. I understand the information will be utilized and relied upon by Stand Energy Corporation in making an initial credit determination for my account. *