Privacy notice

This form asks for sensitive personal information, including your date of birth, the last 4 digits of your Social Security number (optional) and your income. It is sent over a secure, encrypted connection to accounting@emmonak.com for processing this request. If you would prefer not to enter this information online, download the PDF version and mail the signed original to Emmonak Corporation, P.O. Box 49, Emmonak, AK 99581.

1 · About you

2 · Address

3 · Income

Employer / source of income

Job title

Years at employer

Gross monthly income ($)

Other monthly income ($)

Other income source

4 · Monthly obligations

5 · Credit you are requesting

What will you primarily use this account for?

Fuel / heating oil at the Tank Farm

Groceries and goods at the Company Store

Asset Rentals (ATVs, snow machines, boat)

Mixed across our operating units

6 · Personal references

7 · Acknowledgements

I consent in writing to a finance charge of 1.5% per month (18.0% APR) on any past-due balance, pursuant to Alaska Stat. 45.45.010.

I authorize Emmonak Corporation to verify the information provided and to obtain consumer credit reports as part of this application.

Individual Credit Application (Net 30)