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site 2066 Broadway South Portland, Maine 04106 * (207) 775-1254 * 1-800-559-1254 * Fax (207) 775-3613 Account Information APPLICANT FULL NAME_______________________________________ Social Security#______ Complete Address_______________________________________________ Phone______________ Email______________ ______________________________________ # of Years_____ Rent______ Own______________ Previous Address_______________________________________________ How Long?__________ Present Landlord or Mortgagee (Name & Address)_________________________________________ Date of Birth_________ # of Dependents___ Single___ Married___ Separated___ Divorced___ Employer_________________________________________________________ # of Years_______ Employer Address________________________________________________ Phone___________ Monthly Income____________________________ Occupation______________________________ CO-APPLICANT NAME__________________ Social Security#__________ Date of Birth________ Email______________ Employer_________________________________________________________ # of Years_______ Employer Address________________________________________________ Phone___________ Previous Fuel Supplier__________________________________ Address______________________ Phone_______________________ Account #_______________________ How Long?___________ Nearest Relative Name______________________________________________________________ Nearest Relative Address_________________________________________ Phone______________ _________________________________________________________________________________ Type of Account applied for (check one) 10 Day same as Cash
Price___ 30 Day Charge___ Budget (Sept thru June)___ By Signing this credit
application you authorize us to check your credit with the Maine Credit Bureau
and all information listed. Unsigned
applications cannot be processed. 1.5% monthly finance charge assessed on
overdue balances. I (we) understand and agree that anytime my
(our) account is past due, credit terms and automatic deliveries may be
suspended without further notice. We charge a $30 fee for all returned
checks. CO-APPLICANT Signature__________________________________ Date_____________________
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