Station Information

No. of Years of Equipment Location
Equipment Location Owned or Leased
No. of Stations Operated by Owner
Brand of Gasoline
No. of Years in Business

Equipment Information

Equipment Type

Company Information

Complete Corp. Business Name *
Doing Business As
Yearly Revenue
Federal Tax ID
Company Phone
Fuel Supplier / Jobber
Billing Street
Billing City
Billing State
Billing Country
Billing Postal Code
Equipment Location (if different from above)

Owner Information

Owner First Name
Owner Last Name
Owner Social Security Number
Percent Ownership
Owner Email Address
Owner Phone Number
Owner Mobile Phone
Owner Street Address
Owner City
Owner State *
Owner Postal Code
Owner Country

2nd Owner Information

If Applicable

Owner 2 First Name
Owner 2 Last Name
Owner 2 Social Security Number
Owner 2 Email Address
Owner 2 Phone Number
Owner 2 Mobile Number
Owner 2 Street Address
Owner 2 City
Owner 2 State
Owner 2 Postal Code
Owner 2 Country
Who is your Patriot Capital Representative?