Form: Account Application ::

The data submitted from this form is encrypted both in transit and at rest. It is not transmitted by e-mail or stored here long term. You will be notified when it is removed.

This information is confidential, and subject to the "Indemnification of Data Liability" clause below.
Indemnification of Data Liability*
TO SUBMIT THIS FORM YOU MUST CHECK "I AGREE": Even the best safeguards can be defeated under the right circumstances. Jack Griggs Inc. hosts this website with a North American web hosting company evaluated for safety and data center security; a first step in securing any website. The data is encrypted in transit through the SSL connection, and "encrypted at rest", meaning the database itself stores the submitted data in an encrypted format that requires a special digital key to unlock. Despite all these measures, nothing is 100% secure. You agree to hold Jack Griggs Inc harmless for any unintended loss of control over the information, and all subsequent effects, submitted through this form.
- I Agree
Credit Check Authorization
- I authorize a credit check
Information About Yourself
Your Full Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Address*
Street Address Address Line 2 City State ZIP Code
How long at current address?*
Telephone Number*
Is your current address also your mailing address?
- Yes
- No
Mailing Address if Different From Above*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Fax Number
Cell Phone Number*
Your E-mail*
Enter Email Confirm Email
Additional Contact Numbers
Have you resided at your current address less than 3 years?*
- Yes
- No
Previous Address (if less than 3 years at present address)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long did you reside at your previous address?*
Driver's License Number*
Present Employer*
How Long?
Occupation
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone
Salary
Information About Your Spouse
If applicable.
Are You Married?
This form will display additional required fields if you answer YES.
- Yes
- No
Spouse's Full Name*
First Middle Last
Spouse's Date of Birth*
MM slash DD slash YYYY
Spouse's Driver's License Number
Spouse's Social Security Number*
Spouse's Employer*
How Long?
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Spouse's Employer Phone
Spouse's Salary
Dwelling
- I rent
- I own
Digital Signature
Your Full Name*
First Middle Last
Today's Date*
MM slash DD slash YYYY
Spouse's Full Name*
First Middle Last
Today's Date - Spouse*
MM slash DD slash YYYY
Digital Signature Acceptance*
When you submit this form,the date stamp created by the system (along with various fields) creates a unique digital signature that is used in place of a physical signature.

The Applicant has delivered this application to Jack Griggs, Inc. as a request to extend credit to the Applicant. Everything that has been stated in this application is correct to the best of the undersigned’s knowledge. The Applicant understands that Jack Griggs Inc. will rely on the truth, accuracy, and completeness of this application. The Applicant certifies that the information supplied herein has been carefully read and is true, correct, and complete.

The undersigned hereby personally guarantees payment of all purchases of any and all products and services from JACK GRIGGS, INC.

The undersigned thereof, whether suit is instituted or not, the prevailing party shall be entitled to reasonable attorney’s fees and costs of litigation in such amount as may be determined by the Court having jurisdiction.

NOTICE: I/We hereby authorize Jack Griggs Inc. or any credit reporting agency employed by you to investigate the Applicants’ credit record, authorized to investigate my/our credit record, contact my/our credit references and any credit bureaus, and report to proper persons and bureaus my/our performance of this agreement, and to answer questions about Jack Griggs Inc. credit experience with me/us.

Guarantor agrees and acknowledges that JACK GRIGGS, INC., and the undersigned are entering into a purchasing agreement in reliance upon Guaranty being provided hereunder by Guarantor, and that this Guarantee is being to enter into this agreement.

ECOA Notice 701:
The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applications on the basis of race, color, religion, national origin, sex, martial status, age (providing the applicant has the capacity to contract): because all or part of the applicants income derives from any public assistance program; or because the applicant has, in good faith, exercise any right under the consumer credit protection act. The Federal Agency what administers compliance with the law concerning the creditor is The Federal Trade Commission, Equal Credit Opportunity Act, Washington, D.C. 20580.
You must check "I understand and agree" to continue.
- I understand and agree
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24 / 7 Emergency Service: 1-(800)-542-4427

Independent Petroleum Distributor Serving Kern, Tulare, Kings & Fresno Counties

Serving Customers Since the Winter of 1933

For Orders and Inquiries In Your Area:

Form: Account Application

This information is confidential, and subject to the "Indemnification of Data Liability" clause below.

Information About Yourself

Information About Your Spouse

Digital Signature

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