Chair City Oil - Online Residential Credit Application
Sensitive Data will be encrypted for security - * Asterisk fields are required


BILLING ACCOUNT INFORMATION

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*Name:      *Social Security #:  
                   
*Mail Address line 1:     line 2:  
                                      
*Mail to City:     *State:     *Zip:  
                         
*Contact Phone:     Cell Phone:  
                             
Contact EMail:  

DELIVERY LOCATION - we deliver to Gardner and surrounding  towns.

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Delivery Address (if different):     City:  

*How long have you been here:   choose one Not in house yet 2 weeks or less 2 weeks to 1 month 1 to 3 months 3 to 6 months 6 months to 1 year 1 to 2 years 2 to 3 years over 3 years   *Ownership:     choose one Own Rent
                                                      
* Owner enter Mortgage Company, tenants enter landlord name:  
                                                                                                              
* Bank you have Checking or Savings Account:  
                                                                                 

EMPLOYMENT - if retired or unemployeed enter that in Employer field

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*Employer:  
                     
*City:     *State:     Phone:  
            

PREVIOUS FUEL SUPPLIER - enter company who provided heat for the last place you lived

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*Fuel Supplier:  
                           
City:     State:     Phone:  

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How did your hear about us:   choose one please Friend or relative Employee Web search Yellow pages Advertisement Your Customer I was a customer Other  

*Close Friend or Relative not living with you:    Phone:  
                                                                             
*If approved, would you like to be put on Automatic Oil Delivery:   YES   NO

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Joint Applicant  Name:      Social Security #:   

Employer:     Phone:  

       Applicant(s) consents to a credit check based upon the information provided on this application for the purpose of extending credit. Any balance remaining unpaid after thirty (30) days after billing date is subject to a finance charge at a periodic rate of 1 1/2% per month (annual rate 18%). If legal proceedings become necessary to enforce collection, the applicant agrees to pay all reasonable collection and attorney fees.

SIGNATURE: BY TYPING MY NAME IN THE BOX BELOW, I AM SIGNIFYING THAT MY TYPED
NAME REPRESENTS MY ACTUAL SIGNATURE.

*Signature of Applicant #1:     Date:  
                                               
Signature of Applicant #2:        Date: