Residential Account Application


1 - Personal Information

First Name
Middle Int. (optional)
Last Name
Email Address
Date of Birth
Address
Confirm Email Address
City
Address 2 (optional)
Zip Code
State
 
Home Phone (10 digits)
Work Phone (optional)
Cell Phone (optional)
 
Home Ownership

How long at this address?
Former Address, City, State, Zip (required)
 

2 - Spouse Information

Spouse Name
Spouse Employer
 
Spouse Address
Spouse Phone

3 - Payment and Delivery Information

In what format would you like your bill? Check One

   
Payment Type - Check One Delivery Type - Check One

If company owned tank, Automatic Delivery required.

Tank Ownership - Check One Tank Size - Check One

Number of Tanks
Propane Used For: Facing the house, please indicate the tank location:
(required)

Special Instructions for Deliveries: (optional) Referral Source:

4 - Credit Policy and Terms

  1. Payments are due upon receipt of invoice.
  2. A late charge may be assessed on all balances over thirty (30) days. This is computed
    by a periodic rate of 1.5% (which is an annual percentage of 18%) on the portion
    of the previous balance over thirty (30) days less payments and credits appearing
    on the statement. An account is considered past due when a late payment charged
    is assessed.
  3. Any account which becomes past due is subject to termination of automatic fuel
    delivery without notice until the account balance is paid in full.
  4. All fuel remains the property of Hunt Country Propane until paid in full.  Hunt Country Propane reserves the right to reclaim any fuel not paid in full.
  5. Should past due account(s) require the assistance of a collection agency and/or
    attorney to obtain payment(s), the credit applicant herein agrees to pay for all
    costs, including any attorney's fees associated with collection and any subsequent
    enforcement action.
  6. A service charge of $30.00 will be added on any check returned by a bank.
  7. Any out of gas resulting from non-payment will incur a start-up fee upon delivery.
  8. Termination of automatic delivery service must be made in writing.


I accept your offer to deliver my requirements of fuel according to the credit terms above.

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