| ACCT.# |
| NAME: TITLE FIRST MIDDLE LAST |
| NAME: SPOUSE |
| MAILING ADDRESS PHONE |
| DELIVERY ADDRESS PHONE |
| TANK SIZE FILL CODE AMOUNT IN TANK ANNUAL USAGE |
| HOT WATER: OIL GAS ELECTRIC ZONE |
| FORMER ADDRESS |
| HIS EMPLOYMENT PHONE |
| HER EMPLOYMENT PHONE |
| OWN HOME YES NO |
| IF NO - LANDLORD NAME, ADDRESS AND PHONE |
| FORMER OIL SUPPLIER REFERENCE |
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| I WOULD LIKE TO BECOME, |
AN AUTOMATIC DELIVERY CUSTOMER ON A PAY-PER-DELIVERY PAYMENT SCHEDULE;
I understand that all invoices are due within net ten (10) days of invoice date, a discount of $.04 per gallon can be taken if delivery is paid 10 days of invoice date. I also understand that failure to make payments could unterrupt my oil deliveries. |
AN AUTOMATIC DELIVERY CUSTOMER ON A BUDGET PAYMENT SCHEDULE;
I will receive budget coupons and will include one with each payment which are dues to GLOBE PETROLEUM by the 10th of the month. My budget will be $ per month beginning and continuing through of each year. I understand that the amount is subject to change based upon annual usage. I also understand that deliveries will not be made if payments fall deliquent. |
| I also understand, regardless of which program I choose, the service contract if applicable, is valid only in my account is up-to-date. I agree that sevice charges not covered under the contract are to be paid within net ten (10) days of the service invoice date and are not to be deducted from budget payments if I have chosen such plan. |
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| Automatic oil delivery will continue annually on current accounts. Cancellation of service and deliveries must be sent in writing at least two weeks before next scheduled automatic oil delivery. |
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| DELIVERY AUTHORITY: The customer agrees to pay the tank wagon price prevailing on the date of delivery, subject to any tax which may be levied. The customer will also accept the meter-printed delivery ticket (without signature) as proof of delivery, unless, other arrangements are made, in writing with our office. |
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| ADDITIONAL COMMENTS: |
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GLOBE PETROLEUM CREDIT POLICY
I understand that invoices will be due and payable when rendered and I agree to pay same. I also agree to a charge of per month on past due balances to be included on the statement.
I also agree that default of payment of my agreed credit terms could interrupt my oil deliveries and service requirements. I agree to pay any collection fee incurred because of default on my part.
I hereby authorize GLOBE PETROLEUM to investigate the information stated above to determine my qualifications and to fix a limit of credit. This agreement is subject to credit approval. |
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| BUYER'S RIGHT TO CANCEL: You, the buyer, may cancel this transaction without penalty or obligation any time prior to midnight of the third business day after the date of transaction. Representations other than those that appear on this contract are null and void. |
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| CUSTOMERS SIGNATURE DATE SS# |
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| GLOBE REPRESENTATIVE DATE LEAD SOURCE |
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