Gas and Oil

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Forms

Primary Account Holder
*Name:
*SSN:	- -
*Home Phone:	() -
Cell Phone:	() -
Secondary Account Holder
Name:
SSN:	- -
Cell Phone:	() -
Delivery Address Information
*Street:
(Optional) Street:
*City:
*State:	*Zip:
*Statement Preference:	Mailed \| Emailed
*Email Address:
Employment Information
Primary Employer ( Add Second Employer)
*Primary Employer:
*Street Address:
(Optional) Address:
*City:
*State:	*Zip:
Second Employer
*Secondary Employer:
*Street Address:
(Optional) Address:
*City:
*State:	*Zip:
Terms of Agreement: TERMS: PAYMENT OF BALANCE DUE NET 30 DAYS FROM STATEMENT DATE. OVERDUE BALANCE WILL ACCRUE A FINANCE CHARGE OF 18% PER ANNUM & ACCOUNT WILL BE SUBJECT TO GAS STATION SHUT-OFF. THE ABOVE INFORMATION IS FOR THE SOLE PURPOSE OF OBTAINING CREDIT & IS WARRANTED TO BE TRUE. I/WE HEREBY AUTHORIZE Bursaw Gas and Oil Inc. TO INVESTIGATE THE REFERENCES LISTED PERTAINING TO MY/OUR CREDIT AND FINANCIAL RESPONSIBILITY.
* I accept to the terms and agreement of this form.
*Initial of Primary Holder:
*Initial of Secondary Holder:
Timestamp:
IP Record: