GLOBAL PETROLEUM, LTD.

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Secure TRANSMISSION. IF THIS FORM DOES NOT LOAD COMPLETELY, PLEASE CLICK HERE, OR CLICK THE REFRESH BUTTON ON YOUR BROWSER. THIS OCCURS DUE TO HIGH TRAFFIC VOLUME ON OUR SECURE SERVER CONNECTION. WE APOLOGIZE FOR THE INCONVENIENCE. PLEASE KEEP TRYING.

If you experience difficulty submitting this form electronically, or do not wish to do so, please fill out the form then double click on any blank area of the page, a print icon will appear on top of the page. You can print the completed form and fax it to us at ( 310 274 6163 ). For assistance please call ( 310 385 0016 ), 24 hours/7 days a week.

APPLICATION FOR;

AGENCY

AND/OR

PURCHASE

SUBMITTED BY

.

If you are applying for Company sales representative, as an individual, please only complete the section 1.

If you wish to purchase petroleum products on behalf of or as a government agency, please only complete section 1 and 2.

PLEASE PROVIDE AS MUCH INFORMATION AS POSSIBLE

Section 1:

FULL NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
COUNTRY
TELEPHONE
TELEFAX
E-MAIL
WEB SITE ,if any

Section 2:
COMPANY OR GOVERNMENT AGENCY
CONTACT PERSON
TELEPHONE/EXTENSION
E-MAIL ADDRESS
Section 3:
COMPANY PRINCIPALS, name/title
YEAR THE COMPANY WAS ESTABLISHED
MAIN PRODUCTS/SERVICES, list
DOES YOUR COMPANY REPRESENTS ANY OTHER MANUFACTURERS/BRANDS AS AN EXCLUSIVE OR NON-EXCLUSIVE AGENT ?
PLEASE LIST ANY BRANCH OFFICE(S).
TOTAL NUMBER OF EMPLOYEES
NUMBER OF FIELD SALES PEOPLE
ANNUAL GROSS SALES (US$)
COMPANY REGISTRATION NO./TAX NO.
TRADE REFERENCES. Please list; company name, address, telephone/fax number, and person to contact. Please list two trade references.
BANK REFERENCES. Please list; Bank name, address, telephone/fax number and person to contact.
ADDITIONAL COMMENTS, please provide any other information that you think would be helpful in evaluation of your application.

INFORMATION ARE FOR EVALUATION PURPOSES ONLY, AND WILL NOT BE SHARED WITH ANY THIRD PARTIES. WE RESERVE THE RIGHT TO CONTACT THE ENTITIES OR PERSON(S) LISTED AS REFERENCE(S) ON THIS APPLICATION FORM.