DEALER APPLICATIONS

AUTHORISATION TO PERFORM A CREDIT ASSESSMENT

I, Identity Number, do hereby give Engen

Petroleum Ltd permission to perform a credit risk assessment on the business entity listed below. I also hereby state that I
am authorized to give such permission to Engen Petroleum Ltd.

Signature Date

Business Entity Details

Account Number/s with Engen:
Legal Entity Type:
Legal Entity Name:
Legal Entity Number:
Trading Name:
Nature of Business:
Physical Address:
Name & ID no of members / directors:
Name & ID no of members / directors:
Name & ID no of members / directors:

Bank Account Details

Account Name:
Banking Institution:
Account Number:
Branch Name:
Branch Number:

Trade References (minimum of three)

Name of Company Contact Person Contact Tel No. Value of Monthly Trade

Please sign and upload form onto your application profile.

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