Petroleum Retailer Product Verification Request Form
Submit this form to request verification of a petroleum product before handling, selling, or stocking. Please provide accurate and complete information for prompt processing.
Requester Name
*
First Name
Last Name
Company or Store Name
*
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email Address
*
example@example.com
Product Name
*
Product Type
*
Please Select
Gasoline
Diesel
Kerosene
Lubricant
Additive
Other
Product Brand or Manufacturer
*
Product Batch or Lot Number
*
Purpose of Verification Request
*
Please Select
Authenticity Check
Quality Assessment
Regulatory Compliance
Supplier Verification
Other
Upload Supporting Documents (e.g., product label, certificate, invoice)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional Verification Notes
Submit Verification Request
Should be Empty: