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Residential Gas Station Account Form

*Please note that Java is required for these forms. Please download here



Primary Account Holder

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Secondary Account Holder

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Delivery Address Information

Mailed | Emailed


Employment Information

Primary Employer ( Add Second Employer)


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.