Step 1 of 6 - PRIMARY APPLICATION INFORMATION 16% PRIMARY APPLICANT INFORMATIONDate* MM slash DD slash YYYY Full Name* First Name Last Name Phone Number*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Social Security No.* Years at Present Address* Own/Rent* Own Rent Previous Address (if less than one year) Date of Birth* MM slash DD slash YYYY Monthly Household Income* No. of Dependents*Employer* Years Employed*Employer's Address* Name of nearest relative NOT in household* Phone*Relative's Address* Mortgage Provider or Landlord Name/Address* SECONDARY APPLICANT INFORMATIONDate MM slash DD slash YYYY Full Name First Last Phone NumberEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth MM slash DD slash YYYY Social Security No. Employer Years Employed Employers Address CREDIT REFERENCES Please list two.Full Name* Relationship* Company* Phone*Address* Full Name Relationship Company Phone NumberAddress TANK INFORMATIONRequest Automatic Fill?* Yes No Tank Size* Type* Fuel Kerosene CREDIT TERMS OF SALE HOME HEATING FUEL PURCHASES 1. Net if paid in full within 30 days from delivery date. 2. Equal Payment Plans available payable by the 15th of each month. 3. All accounts over 30 days are subject to a finance charge of 1 ½% per month (18 % per annum). 4. All balances more than 90 days past due are subject to legal collection procedures. Your account is an open end retail credit account as defined in the Federal Truth in Lending Act. 1. Finance charges are imposed only if the customer elects not to pay the current charges in full within thirty (30) days from the billing date. If the “new balance” is paid in full within thirty (30) days of the billing date, no finance charge is imposed. 2. Finance charges are computed and determined as follows: a. From the “previous balance”, payments and credits are first deducted. b. The finance charge is next imposed by applying a monthly “Periodic Rate” to said “Previous Balance” after deducting payments and credits, with no “minimum or transaction charge” imposed. Said “Periodic Rate” of 1 ½% per month is an ANNUAL PERCENTAGE RATE OF 18% which applies to all MONTHLY UNPAID BALANCES. c. Finally, charges for current month’s purchases of merchandise and services will be applied in determining the new balance. DISCLAIMER AND SIGNATURES This information is given to obtain credit and is true and complete. You can exchange credit experience on the account with other creditor reporting agencies. I/We agree to the terms and conditions above. This information is to be used for credit verification.Primary Applicant Signature*Date* MM slash DD slash YYYY Secondary Applicant Signature*Date* MM slash DD slash YYYY CAPTCHA Δ
