Credit Application

Note: All information marked with an "*" is required.

Application Type	Individual Joint
Individual Application Information
Last Name*
First Name*
Middle Initial
JR/SR
Social Security No.*
Date of Birth (mm/dd/yy)*
Home Tel. No.*
Employeer Name*
Work Tel. No.*
Cell Phone
Email
Joint Application Information (Co-applicant) Note: Information marked with "**" is required if filing a Joint application. When filing a joint application, information marked with "*" on the Individual Application is also required for the co-applocant.
Last Name**
First Name**
Middle Initial
JR/SR
Social Security No.**
Date of Birth (mm/dd/yy)**
Home Tel. No.**
Employeer Name**
Work Tel. No.**
Cell Phone
Email
Applicant's Present Address
Street Address*
City/Town/Village*
State*
Zip*
Delivery Address (if different than billing address)
Your Previous Address
Do you own or rent:
Own Rent
If you rent please provide the following:
Landlord Name:
Landlord Phone:
You are entitled to provide us with a third party contact:
Name
Address
Phone
Referral:
How did you hear about Heritagenergy?
Who referred you?
Salesperson's Name
To be called in the event we are unable to contact you about an impending fuel run out due to credit hold. We are not responsible for run outs on will call accounts, credit holds for which written or verbal forewarning was given, and unpredictable changes in fuel usages.

WE MAY REQUEST A CONSUMER REPORT IN CONNECTION WITH THIS APPLICATION AND WE MAY ALSO REQUEST SUBSEQUENT REPORTS DURING THE CONTINUATION OF THIS ACCOUNT UPON YOUR REQUEST, WE WILL TELL YOU WHETHER OR NOT A CONSUMER REPORT WAS REQUESTED. AND IF ONE WAS. WE WILL TELL YOU THE NAME AND ADDRESS OF THE CONSUMER REPORTING AGENCY THAT FURNISHED THE REPORT. INFORMATION CONCERNING YOUR ACCOUNT MAY BE REPORTED BY US TO CREDIT REPORTING AGENCIES AND/OR OTHER INTERESTED PARTIES. PLEASE FAMILIARIZE YOURSELF WITH THE FOLLOWING CREDIT TERMS AND CONDITIONS: CREDIT APPROVED ACCOUNTS ARE DUE AND PAYABLE ACCORDING TO THE TERMS SET FORTH BY THE CREDIT DEPARTMENT YOU WILL BE NOTIFIED IN WRITING SUBSEQUENT TO OUR RECEIPT OF THIS COMPLETED FORM. ALL OTHER ACCOUNTS ARE CONSIDERED CASH IN ADVANCE AND MUST HAVE PAYMENT INTO OUR OFFICE PRIOR TO THE DELIVERY OF FUEL OR SERVICE. ALL ACCOUNTS NOT PAID WITHIN THEIR SPECIFIED CREDIT TERMS ARE SUBJECT TO AN 18% PER ANNUM FINANCE CHARGE. RATE SUBJECT TO CHANGE WITHOUT NOTICE. ALL AUTHORIZED INDIVIDUALS ON THIS APPLICATION REMAIN SO AUTHORIZED UNLESS WE ARE NOTIFIED IN WRITING, BY CERTIFIED MAIL, RETURN RECEIPT, TO THE CONTRARY IF APPLICATION IS FILED JOINTLY BOTH PARTIES AGREE TO EQUAL RESPONSIBILITY FOR ALL COSTS INCURRED. ANY CHANGE IN DELIVERY STATUS MUST BE SUBMITTED IN WRITING. IF YOUR ACCOUNT IS SUBMITTED FOR COLLECTION, BY SIGNING THIS CREDIT APPLICATION YOU ACKNOWLEDGE THAT YOU ARE RESPONSIBLE INDIVIDUALLY FOR ALL CHARGES HERETO. ALL COLLECTION AGENCY COSTS, COSTS BY STATUTE AND REASONABLE ATTORNEYS’ FEES. CREDIT EXTENDED UNDER THIS APPLICATION IS TO THE INDIVIDUALS NAMED HEREIN ONLY, AND THAT ANY CHANGE IN OWNERSHIP MUST BE APPROVED IN WRITING BY THE CREDITOR. CASH IN ADVANCE AND WILL CALL CUSTOMERS MAY BE ASKED TO ALLOW 5 WORKING DAYS NOTICE FOR DELIVERIES OR SERVICE. ANY OVERDUE BALANCE MAY RESULT IN THE DELAY OF SCHEDULED FUEL DELIVERIES OR SERVICE. CHECKS RETURNED TO US BY THE BANK WILL RESULT IN A CHARGE OF $15 FOR THE FIRST ATTEMPT AND $20 FOR THE SECOND ATTEMPT. IF A CHECK CANNOT BE CLEARED PROSECUTION WILL BE INITIATED. RETURN CHECK FEE IS SUBJECT TO CHANGE WITHOUT NOTICE PROPANE GAS CUSTOMERS ARE REQUIRED TO PURCHASE A MINIMUM AMOUNT OF PROPANE PER YEAR AND ARE SUBJECT TO AN ENVIRONMENTAL FEE PER DELIVERY ALL PROPANE SALES ARE FINAL.

By submitting this information I (we) hereby acknowledge that the information contained on this application is correct and that I (we) understand the terms and policies set forth by this application.