Residential Customer Application Form

This application is subject to credit check.

Your Information:
Name: (First, MI, Last)	Mr.   Ms.   Mrs.
Formerly:
Account Number:
Social Security Number:	- -
Drivers License Number:
Spouse Name: (First, MI, Last)	Mr.   Ms.   Mrs.
Spouse Social Security Number:	- -
Spouse Drivers License Number:
Billing Address: (City, State, ZIP)	AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Delivery Address: (City, State, ZIP)	AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Phone:	() -
Work:	() -
Other:	() -
Email:
Employment Information:
Employer:
Address: (City, State, ZIP)	AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Phone:	() -
Supervision:
How Long Employed:
Type of Work:
Spouse's Employer:
Address: (City, State, ZIP)	AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Phone:	() -
Supervision:
How Long Employed:
Type of Work:
Name Of Nearest Relative:
Address: (City, State, ZIP)	AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Phone:	() -
Housing	Own      Rent
Landlord:
Landlord's Address: (City, State, ZIP)	AL AK AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NY NV OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Landlord's Phone:	() -
Landlord's Email:
Delivery:	Fuel Oil Delivery       Kerosene Delivery
Delivery Type:	Automatic Delivery       Will Call Delivery
Account Type:	30 Day Account       Budget Account  C.O.D. Account
Do You Use Fuel Oil To Heat Water For Domestic Use?	Yes       No
Gallons:
All deliveris will be C.O.D. until credit application is approved Payment is due upon receipt of invoice. Invoices not paid within 30-days are subject to 1.5% per month late fee until the account is paid in full. If the account is referred to a collection agency or an attorney for collection, I/we shall be responsible for the attorney's fees, collection agency fees plus any costs associated with collecition.
Please correctly type in the following phrase to verify:
Please type l.a.u.r.e.l. without the periods in the box to the right.