RESIDENTIAL CREDIT APPLICATION - Fill out - Print and Send to West Side Oil, 3650 Mountain Road, West Suffield, CT 06093 - 860-668-4322    Fax: 860-668-1557
Name
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Social Security Number
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Do you Rent or Own?
 
How many years have you live there?
Credit References
Bank Name
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Local Credit References:  Dept. Stores, Bank Cards, Etc.
Reference 1 Name
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Account Monthly Payment
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Reference 2 Name
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Account Monthly Payment
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Reference 3 Name
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Account Monthly Payment
Account Balance
I would like information on the following services:
Automatic Delivery
Budget Payment Plan
Account to be paid in full within thirty(30) days. Under the terms of this agreement the customer shall be subject to interest and collection fees on past due accounts.  We certify that all the information on this form is correct.  We fully understand your credit terms and agree to proper payment in consideration of extended credit.  This is your authorization to supply my oil needs until further notice.  I agree to pay your tank wagon price prevailing on the day of delivery, subject to any tax which might be levied.  I will also accept your meter printed delivery ticket (without my signature) as proof of delivery and I will give you written notice upon termination of deliveries.

Customer Signature ______________________________   DATE:  _________________________

THIS IS NOT A SECURE FORM - PLEASE PRINT OUT THE FILLED-OUT FORM AND SEND IT BY MAIL.  ANY E-MAIL SUBMISSIONS ARE AT YOUR OWN RISK.

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Copyright © 2000 [West Side Oil, Co.]. All rights reserved.
Revised: December 07, 2005 .