Application to State for Petroleum Product Hardship or Emergency Relief Case

(Form EPC- 1)                        

1. Applicant Identification:

Company/Agency Name:  Case #

Address:    City: State: CO KS WY DE  Zip Code:

Contact Person:  Phone: Fax:

 E-Mail: Date Requested:

2. Applicants Classification:

3. Justification:

4. Product:

4a. Amount:

Wholesaler-Purchaser-Consumer End-User Wholesaler-Purchaser-Reseller Dealer

5. Additional Justification:

6. Supplier: My existing supplier (or alternate) named below can supply the quantity requested:

Supplier #1

Name: Contact:

Phone:   Fax:   E-Mail:

Street Address: City: State:   Zip Code:

Supplier #2

Name: Contact:

Phone:   Fax:   E-Mail:

Street Address: City: State:   Zip Code:

7.CERTIFICATION:

I certify that the above information is true and accurate and that any quantity granted will be used for the purpose herein described and will not be delivered to another user:

Name Printed:   Title:    Date: