Social Security Number _________-______-____________
Delivery Address __________________________________________________ City _________________________ Zip _____________
Billing Address __________________________________________________ City _________________________ Zip _____________
Home Telephone _________-_________-_____________ Business Telephone _________-_________-______________
Delivery Residence: Own_____ Rent_____ How Long______ Email address _____________________@________________
Address _________________________________________________________ City __________________________ Zip _____________
How long there? _____________
I have read and do hearby accept the terms of the attached Heating Oil Supply Agreement and authorize Clarke Brothers, Inc. to obtain a Credit Report.
Signature of Applicant __________________________________________ Date _____________________________________
HEATING OIL SUPPLY AGREEMENT
CUSTOMER COPY OF AGREEMENT:
I, the forementioned, hereby authorize you to make automatic deliveries of heating oil to me until further notice for which I will pay your posted retail price in effect
at the time and place of delivery. I also consent to a credit check based on the information provided on this application that terms of payment are as follows:
Balances remaining unpaid 30 (thirty) days after billing date are subject to a FINANCE CHARGE of 1 1/2 % per month. (ANNUAL PERCENTAGE RATE 18%.)
A FINANCE CHARGE of 1% per month (ANNUAL PERCENTAGE RATE 12%) will be applied to that portion of the overdue balance exceeding $500.00. The
FINANCE CHARGE will be computed monthly on the outstanding unpaid balance over 60 days old after crediting current payments. Term may be amended by the
company at its sole option upon at least one full billing period notice.
BUDGET CUSTOMERS ONLY:
Failure to pay budget payments or to pay any current non-budget items will result in termination of budget plan participation in accordance with applicable laws. You
will then be considered a regular charge customer subject to all of the terms applicable to such customers.
In the event that my account is forwarded to an attorney for collection, I agree to pay all attorney’s fees which you incur in effecting payment.
The seller shall not be responsible for failure to make deliveries due to conditions beyond its control including but not limited to interruption of supply, strikes, fires,
accidents, government regulations or any cause whatsoever beyond its reasonable control.
NOTICE TO BUYER:
1. Do not sign this agreement if any of the spaces intended for the agreed terms are left blank.
2. You are entitled to a copy of this agreement at the time you sign it.
3. You may at any time pay off the full unpaid balance under this agreement.
DELIVERIES: Unless otherwise specified, deliveries will be made in accordance with the company’s automatic Weather-Controlled Service. Use of this service
does not nullify the customer’s basic and primary responsibility to ensure that an adequate fuel inventory is on hand.
It is the responsibility of the customer to maintain clear approaches to the fill location.
NOTICE: The Federal Equal Credit Opportunity Act prohibits credit from discriminating against credit applicants on the basis of sex or marital status. The Federal
agency which administers compliance with this law concerning this company is the Federal Trade Commission, Washington, D.C. 02580.
281 Derby Street, P.O. Box 829, Salem, MA 01970-0829 Tel: 978-745-1007 Fax: 978-745-4309
FOR OFFICE USE ONLY
OIL DELIVERY INFORMATION
New Account _________________________ Existing Account _______________________
Delivery Address _________________________________ City __________________ Zip _____________
Gals in Tank________________ Date ____________/First Delivery Date______________________
Grade Oil______________________ Estimate of Gallons Used_________________________
Tank Size _______________ Inside ______________ Outside ______________Vent Alarm Yes_____
TYPE of DELIVERY
D.D Auto ___________________ Calendar Auto __________________ Will Call ____________________
Special Instructions ________________________________________________________________________
BUDGET Amount _______________ Beginning _______________ Ending _______________
Salesman __________________________________ Price Code ________________ per _________________
Make Burner _____________________________________ Model _______________________
Make Unit ________________________________________ Model _______________________
Type System FHW ___ GHW_____
FWA ___ GWA_____
STEAM ___ VAPOR_____
Domestic Hot Water Yes___________ No_____________
Qualifies for Service Policy _____________________________________