R.E. Hinkley Co. Account Application

R.E. Hinkley Co., Inc. Account Application

8 Lane Ridge Rd Claremont, NH 03743 603-543-3571
Account No.
Transfer from Account No.
Name*

First NameLast Name
Delivery Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
House Location Directions (Please list details to help us find where you are located - Number on house, color, side of street. For additional drop locations please add details.)*
Oil Fill Location Directions (If standing in street or driveway looking at house)*
Location Directions*
E-mail:*
Home Phone:*

Area CodePhone Number
Work Phone:

Area CodePhone Number
Cell or Emergency Phone:*

Area CodePhone Number
Bill to:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
My Previous Energy Supplier:

THIS IS MY ORDER: I wish to purchase heating fuel, propane gas, and other products and services and I agree to make payment in accordance with R.E. Hinkley Co.'s REGULAR, BUDGET, PRE-BUY, SECURITY, or RENTAL HEATING CREDIT REQUIRED plan. I would also like any other services that I may need subject to acceptance.*

Yes I doNo I do not currently have any outstanding judgement or filed for bankruptcy, had a debt adjusted plan confirmed under Chapter 13, had property foreclosed upon or repossessed in the last 7 years or a party to a lawsuit. If yes, attach details.
(1) Do not sign this agreement if any of the spaces intended for the agreed terms are left blank. (2) I am entitled to a copy of this agreement at the time I sign it. (3) I may at any time pay off the full unpaid balance under this agreement. (4) I may cancel a purchase under this agreement if it has been consummated by a party thereto at a place other than the address of the seller which may be his main office or branch thereof: provided; I notify the seller in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third buisness day following a purchase under this agreement.
BUYER(S) NAME PRINTED:*
BUYER(S) SIGNATURE:*
Date:*
THIS AGREEMENT IS BINDING ON COMPANY ONLY AFTER IT IS ACCEPTED BY AN AUTHORIZED REPRESENTATIVE.
Should be Empty:

R.E. Hinkley Co., Inc. Account Application