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Apply for Credit

Credit Application for Oil and/or Service
(*required fields)

*First Name:
 		Account #:
*Last Name:
*Home Address:
 		*Years There:
*City:
*State:
*Zip Code:
*Email
*Mailing Address:
*City:
*State:
*Zip Code:
Previous Address:
City:
State:
Zip Code:
*Home Phone:
 		Cell Phone:
 		*Social Security #:
 		*Birth Date:
Landlord - if you rent:
 		Phone:
Your Employer:
 		Work Phone:
Check One:
Service Acct      Oil Acct       Both       Other      
For Service Customers - check all that apply
Plumbing
 Air Conditioning
 Refrigeration		 Water Treatment
 Type of Heat
 Hot Water
Equipment Description:
For Oil Customers - check all that apply
Tank Size:
 		Tank Guard:
 Yes   No		 Fill Location:
 		 
Oil for Heat
 Hot Water		 Automatic Delivery
 Will call for delivery
Last Three Deliveries (dates and gallons):
 		Do you Burn Wood?:
 Yes  No
Amount of Oil in Tank Today:
 		Annual Gallons:
Type of House:
 		Color:
Special Directions:

Credit Agreement and Billing Errors Information Disclosure

I/we hereby acknowledge that I/we have read and understand the Credit Agreement and Billing Errors Information Disclosure.
(Your initials here - required)

By Submitting this form you are certifying the following:
EVERYTHING THAT I HAVE STATED IN THIS APPLICATION IS CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT YOU WILL RETAIN THIS APPLICATION WHETHER OR NOT IT IS APPROVED. YOU ARE AUTHORIZED TO CHECK MY CREDIT AND EMPLOYMENT HISTORY AND ANSWER QUESTIONS ABOUT YOUR CREDIT EXPERIENCES WITH ME.
 


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