Address Change

 

Please fill out the form below to submit an Address Change to CountryMark. For questions please Email: Division.Order@CountryMark.com , Fax: 812.838.8175 or Call: 800.832.5490 extension 8141.


* Required
 
* CountryMark Owner Number:
  (Located on Remittance Advice)
* Last Four Digits of SSN or Federal Tax ID:
 
* Owner Name(s): (at least one is required)
 
 
 
* Old Address:
* New Address:
 
By the execution of this document, owner directs Countrymark Refining and Logistics, LLC to make the address change set out above.
 
* Owner's Signature:
  
* Date:
 
Co-Owner's Signature:
Date:
 
Company/Corporation Signature:

(Capacity of Signor)
Date:

 
* Email Address:
  
* Phone Number:
 
Note: Please be sure to insert information that pertains to the account currently paid by CountryMark for crude oil purchases. Incomplete forms will be returned to owner and changes will not be made until corrected.

 

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