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Thank you for applying for credit with Casey’s. Please provide supplier credit references for our review:

Your Company Name: ___________________________________________________

Supplier #1 Name:

Supplier #1 Email Address:

Supplier #1 Account #:

Supplier #2 Name:

Supplier #2 Email Address:

Supplier #2 Account #:

Supplier #3 Name:

Supplier #3 Email Address:

Supplier #3 Account #:

Please complete this form and return via email: accountsreceivable@caseys-distributing.com or fax to (402) 625-0501. Please return in a timely manner so a response can be provided to you on your pending credit application. All information is confidential and used only for the purpose of extending credit.

Casey’s Distributing, Inc.     8921 J. Street     Omaha     NE     68127     (402) 334-3485     www.caseys-distributing.com