We would appreciate it if you would take a few moments to answer the following questions.

Personal Information

First Name:
Last Name:
Billing Address:
Delivery Address:
City:
State:
Zip:
Phone:
Email:
SSN:
Drivers License #:
Credit Card #1:
Account #1:
Credit Card #2:
Account #2:

 

Employment Information

    
Employment Status:
# Years:
Employer:
Position :
Address:
Phone:

 

Spouse or Partner's Employment Information
 
First Name:
Last Name:
Employment Status:
# Years :
Employer:
Position :
Address:
Phone:

 

Home Information
 
Are you a
# Years at present address:
Mortgage With:
How would you like your deliveries?
Tank Size:
Amount of oil in your tank now
How is your domestic hot water heated?
Sq. Ft. of Living Space in your house
Type of Heating System:
Approximate age and make of your heating system:
Approximate amount of oil used in a year:
Additional Information:
 

I (We) hereby certify that I (We) have read the Retail Credit Agreement thoroughly and accept its conditions, and further state that all information supplied by me (us) is true in fact and intent.

 

 

 

 


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