RESIDENTIAL PROPANE CREDIT APPLICATION

CUSTOMER INFORMATION

FIRST NAME *

MIDDLE NAME

LAST NAME *

BIRTH DATE (M/D/Y) *

MAILING ADDRESS *

DELIVERY ADDRESS *

PHONE *

FAX *

CELL

EMAIL *

EMAIL STATEMENT

YES

NO

EMPLOYER *

YEARS WITH EMPLOYER *

POSITION *

SPOUSE NAME

SPOUSE EMPLOYER

HOW LONG AT PRESENT ADDRESS *

PREVIOUS ADDRESS IF LESS THAN 2 YEARS *

PREVIOUS OWNER OR OCCUPANT *

PREVIOUS FUEL SUPPLIER

CO-SIGNER

CO-SIGNER /ALT CONTACT

EMAIL

CO-SIGNER PHONE

CO-SIGNER CELL

CO-SIGNER WORK

BANK REFERENCE

BANK NAME *

CONTACT NAME *

BRANCH NUMBER *

PHONE *

EMAIL *

REFERENCES (i.e. Finance Co, Mortgage Co, Visa etc) *

DELIVERY DETAILS

(OFFICE): ____________________

DELIVERY METHOD *

AUTO DELIVERY

CASH (C.O.D / PREPAY)

FREQUENCY *

NUMBER OF TANKS *

TANK SIZE *

STORAGE CAPACITY *

TANK LOCATION *

DWELLING TYPE *

USE OF DRIVEWAY *

YES

NO

TOTAL BTU *

ESTIMATED MONTHLY USAGE (LTR) *

DOMESTIC H/W *

FIREPLACE

OCCASIONAL

SPACE HEATING

FIRST DELIVERY REQUIRED *

CUSTOMER OWNS TANK *

YES

NO

CUSTOMER TANK INSTALLATION *

YES

NO

TERMS & CONDITIONS

PARK FUELS PROPANE WILL SUPPLY CUSTOMER’S REQUIREMENTS OF PROPANE AT THE ABOVE ADDRESS COMMENCING ___________________ 20 __________ AS DESIGNATED UNDER THE TERMS OF THE RENTAL AGREEMENT AND YEAR TO YEAR THEREAFTER 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 PROPANE 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 MY ACCOUNT BECOMES PAST DUE, AUTOMATIC DELIVERY OF PROPANE MAY BE SUSPENDED.

PARK FUELS PROPANE WILL NOT BE RESPONSIBLE FOR FAILURE TO MAKE DELIVERIES DUE TO ANY CAUSE REASONABLE BEYOND ITS CONTROL.

I, THE UNDERSIGNED AUTHORIZE PARK FUELS PROPANE. 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 PROPANE, INCLUDING ANY AND ALL LEGAL FEES AND DISBURSEMENTS AND/OR COLLECTION AGENCY COSTS AND/OR ANY OTHER SIMILAR RELATED COSTS INCURRED BY PARK FUELS PROPANE, IN RECOVERING PAYMENT; ALL ON A FULL INDEMNITY BASIS.

DATE *

CUSTOMER SIGNATURE *

Draw It
Type It
Clear

DATE *

PARK FUELS REPRESENTATIVE SIGNATURE *

Draw It
Type It
Clear

3RD PARTY AUTHORIZATION:
My signature also authorizes *

to give instruction and incur costs for either propane delivery and/or technical services, on my behalf, as may be required from time-to-time. Prior confirmation, by me, to Park Fuels Propane 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