RESIDENTIAL HEATING OIL APPLICATION

CREDIT APPLICATION & HEATING OIL APPLICATION

CUSTOMER INFORMATION

FIRST NAME *

MIDDLE NAME

LAST NAME *

MAILING ADDRESS *

PHONE *

FAX *

DELIVERY ADDRESS *

CELL

EMAIL *

BIRTH DATE *

SPOUSE NAME

SPOUSE EMPLOYER

EMPLOYER *

YEARS WITH EMPLOYER *

POSITION *

HOW LONG AT PRESENT ADDRESS *

PREVIOUS ADDRESS IF LESS THAN 2 YEARS *

PREVIOUS OWNER OR OCCUPANT *

PREVIOUS FUEL SUPPLIER

CO-SIGNER /ALT CONTACT

CO-SIGNER EMAIL

CO-SIGNER PHONE

CO-SIGNER CELL

CO-SIGNER WORK

BANKING INFORMATION

BANK NAME *

BRANCH NUMBER *

PHONE *

CONTACT NAME *

CONTACT EMAIL *

REFERENCES *

(I.E. FINANCE CO, MORTGAGE CO, VISA ETC)

*

DELIVERY DETAILS · OFFICE ______________

DELIVERY METHOD *

AUTO DELIVERY

CALL

C.O.D

FREQUENCY *

TYPE OF PRODUCT *

NUMBER OF TANKS *

TANK CAPACITY *

FUEL TANKS *

INSIDE

OUTSIDE

FILL PIPE LOCATION *

RENT OR OWN *

RENT

OWN

DWELLING TYPE *

# OF ROOMS HEATED *

DOMESTIC H/W *

OIL

ELECTRIC

GAS

OIL LEVEL *

USE OF DRIVEWAY *

YES

NO

FIRST DELIVERY REQUIRED *

DESIRES P/P *

# OF UNITS FOR P/P *

BUDGET PLAN

YES

NO

TERMS AND CONDITIONS

PARK FUELS WILL SUPPLY CUSTOMER’S REQUIREMENTS OF HEATING OIL AT THE ABOVE ADDRESS COMMENCING ______________________ 20 _________________ FOR A PERIOD OF ONE YEAR AND YEAR TO YEAR THERE AFTER UNTIL TERMINATED IN WRITING.

WHILE THERE IS NO FIXED MONETARY LIMIT ON THE CREDIT THAT WILL BE EXTENDED UNDER THIS AGREEMENT, THE CUSTOMER IS EXPECTED TO USE SUCH CREDIT ONLY FOR HIS/HER REASONABLE REQUIREMENTS.

CUSTOMER WILL NOTIFY PARK FUELS IN ADVANCE SHOULD CUSTOMER VACATE THE PREMISES.

PAYMENT IS DUE 30 DAYS FROM THE DATE OF THE DELIVERY. SERVICE CHARGES ARE APPLICABLE TO ACCOUNTS NOT PAID WITHIN THE 30 DAY TERMS AND ARE ASSESSED AT 2% PER MONTH (26.82% PER ANNUM) ON THE TOTAL BALANCE 30 DAYS OR MORE PAST DUE. Initial: ____________________

IF ANY ACCOUNT BECOMES PAST DUE, AUTOMATIC DELIVERY OF OIL MAY BE SUSPENDED. PARK FUELS WILL NOT BE RESPONSIBLE FOR FAILURE TO MAKE DELIVERIES DUE TO ANY CAUSE REASONABLE BEYOND ITS CONTROL.

I, THE UNDERSIGNED AUTHORIZE PARK FUELS LTD. TO VERIFY THE INFORMATION CONTAINED IN THIS REQUEST INCLUDING AUTHORIZATION TO OBTAIN A CREDIT REPORT.

I ALSO AUTHORIZE THE PERSONS NAMED AS REFERENCES AS WELL AS MY BANK TO GIVE ADDITIONAL INFORMATION WHICH IS CONSIDERED NECESSARY IN OBTAINING MY MARGIN OF CREDIT.

DEFAULT AND COLLECTION CHARGES:

I FURTHER AGREE TO PAY ACTUAL COLLECTION COSTS AND EXPENSES INCURRED BY PARK FUELS, INCLUDING ANY AND ALL LEGAL FEES AND DISBURSEMENTS AND/OR COLLECTION AGENCY COSTS AND/OR ANY OTHER SIMILAR RELATED COSTS INCURRED BY PARK FUELS, IN RECOVERING PAYMENT; ALL ON A FULL INDEMNITY BASIS.

I AGREE TO THE ABOVE CONDITIONS:

DATE *

CUSTOMER SIGNATURE *

Draw It
Type It
Clear

DATE *

3RD PARTY AUTHORIZATION:
My signature also authorizes *

to give instruction and incur costs for either oil delivery and/or technical services, on my behalf, as may be required from time-to-time. Prior confirmation, by me, to Park Fuels Ltd. or LeRoy’s Heating Services Ltd. is not required. Any applicable charges or costs will be charged to this account and payable within normal terms as agreed by me.