Customer Information | Please fill out the information below

RESIDENTIAL

First Name *

Middle Name *

Last Name *

Date Of Birth *

Phone Number *

Social Security Number

Driver’s License Number

Home Address *

Apt, suite, etc.

Country

City

State

Zip code

Name, Address, Phone of Previous Fuel Supplier

PLEASE READ THIS SECTION AND SIGN

i authorize you to obtain such information as you may require concerning the statements made in this application for credit. i affirm that i have read each of the answers given to the foregoing questions and agree that they are correct. credit terms- if credit is approved i understand and agree to the following terms: all charges are to be paid net 10. a late charge of 1 ½ % per month (18% per annum) may be assessed on any balance not paid within 10 days from the date of the charge. service may be discontinued on any account that is past due. if it should become necessary to place my account with a collection agency, i agree to pay all expenses including collection fees, attorney fees, and fines.

Applicant's Signature *

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Date *

Co-Applicant's Signature

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our acceptance of this application and agreement is subject to credit approval. we may order a consumer report in connection with this agreement. subsequent consumer reports in connection with updating, renewing, and reviewing the existing or future extensions of credit. upon your request, we will provide the name and address of the consumer credit reporting agency furnishing such report to us. the federal equal credit opportunity act prohibits us from discriminating against you in the granting of credit. the federal agency, which administers compliance with this law, is the federal trade commission. we have given to you and you acknowledge receipt of important terms and conditions and your billing rights. this agreement is binding on the parties when it has been signed by our company representative.

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