Credit Application

Please complete and submit the form below to apply for credit with Cox Fuel Co., Inc. We will contact you after the application has been approved.

Thank you for your interest in Cox Fuel Co., Inc.

Applicant's Name *

First

Last

Email *

Social Security # *

Co-Applicant's Name *

First

Last

Email *

Social Security # *

Home Phone *

Cell *

Billing Address *

Address Line 1

City

State

Zip Code

How Long Have You Been At This Address? *

Own or Rent? *

Own
Rent

Delivery Address *

Address Line 1

City

State

Zip Code

Mortgage Bank / Landlord *

Address *

Address Line 1

City

State

Zip Code

Employment Information

Applicant's Employment *

Address *

Address Line 1

City

State

Zip Code

Employer's Phone *

Years With Company *

Position *

Applicant's Previous Employer if less than one year *

Address *

Address Line 1

City

State

Zip Code

Co-Applicant's Employment *

Address *

Address Line 1

City

State

Zip Code

Phone *

Years With Company *

Position *

Credit References

Bank *

Address *

Address Line 1

City

State

Zip Code

Phone *

Account Number *

Account Type (select one) *

Savings
Checking

Name On Credit Card *

Credit Card Number *

Emergency Contact

Name (person not living with you) *

Address *

Address Line 1

City

State

Zip Code

Phone *

Message

Winter Business Hours:
Monday thru Friday 8:00 am – 4:30 pm
Saturday 8:00 am. to Noon
Closed Sunday

Please contact office for all NON-EMERGENCY calls during business hours, e.g. pricing, billing etc.

24/7 EMERGENCY SERVICE

Schedule a Delivery

Credit Application

Employment Information

Credit References

Emergency Contact

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