New ONSITE PROPANE RESIDENTIAL CREDIT APPLICATION

RESIDENTIAL CREDIT APPLICATION
Onsite Propane

PO Box 183
6 John Putnam Memorial Dr.
Cambridge, VT 05444
802-644-5500

Credit application and contract to purchase propane through temperature controlled deliveries and/or heating related services.
Applicant Name*

First NameLast Name
Applicant's Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant's Physical Address (if different than mailing address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant Phone Number*
Applicant Date of Birth*

MonthDayYear
Date
Applicant's Email*
example@example.com
Do You... ?*

OwnRent (renting requires landlord as co-applicant)
Co-Applicant Name

First NameLast Name
Co-Applicant Mailing Address

Address

Physical Address

CityState / Province

Postal / Zip Code
Co-Applicant Phone Number
Co-Applicant Date of Birth

MonthDayYear
Date
Co-Applicant SS# _ _ _ - _ _ - _ _ _ _
Co-Applicant's Email
example@example.com
RELATIVE NOT LIVING WITH YOU
Relative's Name

First NameLast Name
Relative's Relationship to Applicant
Relative's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relative's Phone Number
EMPLOYER
Applicant's Employer*
Applicant's Employer's Phone Number*
Co-Applicant's Employer
Co-Applicant's Employer's Phone Number
PROPANE INFORMATION
Delivery Address (if different from Applicant)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What Do You Use Propane For (check all that apply)

HeatCookingHot WaterDryerOther
Current Propane Provider
Tank Size
Tank Location

Above GroundUnderground
Average Gallons Used Per Year
AGREEMENT

Customer(s) agree that tanks and equipment supplied by Onsite Propane including above ground tanks, below ground tanks, regulators, fittings, gas piping or any associated part of the aforementioned are the sole property of Onsite Propane. Customer will allow Onsite Propane access to all products at any timefor repair, maintenance, servicing, service or removal. Customer shall not allow nor solicit any other company to utilize equipment owned by Onsite Propane.

For delivery efficiency all accounts will be automatice delivery.

Once a delivery has been made, payment for product shall be made within 15 days unless agreed upon otherwise in writing. All accounts with balances over 30 days are subject to interest at the rate of 1.5% per month. Customer agrees to pay any and all costs of collecting overdue accounts.

Checks returned to us by the bank will result in a $35.00 fee.

Applicant and Co-Applicant are jointly responsible for all costs incurred through this account.

Applicant(s) agree to review all safety information and Onsite Propane policies and procedures prior to signing this document.
I/We have reviewed all safety information and Onsite Propane policies and procedures*

yes
I/We certify that all the above information is correct. We fully understand your credit terms and agree to the proper payment in consideration of extended credit. We authorize the release of credit information to Onsite Propane.
Applicant's Signature*

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Date of Applicant's Signature*

MonthDayYear
Date
Co-Applicant's Signature

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Date of Co-Applicant's Signature

MonthDayYear
Date
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