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RESIDENTIAL NEW CUSTOMER APPLICATION

PREFER TO FILL THIS APPLICATION OUT BY HAND?
CLICK HERE FOR A PDF TO PRINT/SEND VIA FAX OR MAIL

INSTRUCTIONS FOR ONLINE APPLICATION BELOW:
1. Please fill out this application in full.
2. Read the Credit Terms & Conditions then click the agree check box.
This will then turn on the SUBMIT button.
3. Click the SUBMIT button on the bottom to submit the final form.
NOTE: You will be sent to a Thank You page when your application is successfully submitted.

*Required Field

 
Customer Applicant

Social Security Number Strictly Confidential
For Credit Verification and Internal Use Only.

Mailing Address

Is your delivery address the same
as your mailing address?

Yes   No

Customer Phone

Employment Information
Choose Payment Plan

accept marks

Select your payment method

Propane Usage

Agree to Terms

CREDIT TERMS AND CONDITIONS: Customer agrees to pay all fees, rates and charges within 15 days of the invoice date to George Propane, Inc. If Customer fails to pay any fees, rates and charges when due, George Propane, Inc., may add a finance charge of 1.5% per month (18% annually) to all past due balances.

George Propane, Inc reserves the right to require payment in advance.

If George Propane, Inc. files suit against Customer to enforce any of the terms and conditions of this Agreement or to recover possession of any of its equipment, the Customer shall pay George Propane, Inc. reasonable costs, including attorney's fees to the maximum extent permitted by law.

Under no circumstance will a credit report be directly or indirectly accessed by, or passed on to, any other business entity or individual unrelated to George Propane, Inc., or be used for any other permissible purpose other than for evaluating the credit worthiness of new customers to extend net 15 day credit for the purchase of propane and/or heating and plumbing services.

I/We fully understand your credit terms and agree to the proper payment in consideration of extended credit.

I/We hereby certify that the facts set forth in the above application are true and complete to the best of my/our knowledge.

If George Propane, Inc. chooses to verify any of the information provided above, you are hereby authorized to make any investigations concerning my financial standing and/or credit record through any investigative or credit agencies.

I/We further acknowledge that credit privileges, if granted, may be withdrawn at any time.

Before submitting please make sure of the following

  • All necessary information has been filled out.
  • All information is error-free.
  • All information is correct and fraud-free.
  • That you have downloaded & filled out any PDF forms that are required.
  • For Fraud Prevention purposes, we have recorded your IP Address & the time of your submission.