Thank you for your interest in Carroll County Oil.

Please Print this page and fill out the application mail it to us.

Or bring it in to our office.
_________________________________________________________________________________

NAME(S): ____________________________________________________________________________

STREET: _____________________________________________________________________________

TOWN: ________________________________________ STATE: __________ ZIP: ________________

HOME PHONE: _____________________________CELL PHONE: _______________________________

SENIOR DISCOUNT (55 OR OLDER) YES___NO___ DOB____________ (Required)

BILLING ADDRESS: (IF DIFFERENT FROM ABOVE)

STREET (PO BOX): _____________________________________________________________________

TOWN: _________________________________________STATE: ___________ ZIP: ________________

RESIDENCE TYPE: OWN ______RENT ______

LANDLORD NAME & NUMBER____________________________________

EMPLOYER’S INFORMATION:

NAME__________________________ ADDRESS: ___________________________PH: ____________

FUEL TYPE #2 _______
KEROSENE _______
MIX/BLEND ________

MONITOR HEATER______ (Yes or No)

**PLEASE NOTE, THAT ALL OUTSIDE TANKS MUST HAVE LINES AND FILTER PROTECTED FROM

POSSIBLE DAMAGE**

TANK CAPACITY ___________ UNDERGROUND TANK? _______________ FILL LOCATION______________________________

FUEL USAGE:
HEAT _____________
WATER____________
BOTH______________

PREVIOUS PRODUCT SUPPLIER____________________________________TOWN______________

PLEASE LET US KNOW HOW MUCH FUEL IS CURRENTLY IN YOUR TANK_______________GALLONS WOULD YOU LIKE A DELIVERY

ON YOUR NEXT DELIVERY DAY? _____________

IF YES, WOULD YOU LIKE A FILL OR JUST A MINIMUM DELIVERY OF 100 GALLONS? ___________________________

WOULD YOU LIKE FOR US TO E-MAIL YOUR STATEMENT? YES_____

PLEASE PROVIDE YOUR E-MAIL ADDRESS_____________________________________________

I understand that payment is due in full on or before my 1st delivery. Please Initial___________

AUTOMATIC (REQUIRES CREDIT/DEBIT CARD BACKUP) ______________WILL CALL_________

MC/VISA/DISCOVER - ACCT #________________________________________EXP_____/_____
CVC CODE (FROM BACK OF CARD) _____________

WOULD YOU LIKE YOUR CREDIT CARD CHARGED FOR EACH DELIVERY? YES_____NO____

I HEREBY CERTIFY THE ABOVE INFORMATION TO BE TRUE AND COMPLETE. BY SIGNING THIS, I AGREE TO CARROLL COUNTY OIL’S TERMS.

I UNDERSTAND A FINANCE CHARGE OF 18% ANNUAL RATE WILL BE APPLIED TO ALL UNPAID BALANCE AFTER 30 DAYS.

I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR ALL COLLECTION FEES INCURRED FOR OUTSTANDING BALANCES.

I UNDERSTAND THERE WILL BE A $30 CHARGE FOR ANY CHECKS RETURNED FOR INSUFFICIANT FUNDS.

SIGNATURE: __________________________________________________________________________

***DIRECTIONS***

PLEASE GIVE DETAILED DIRECTIONS TO YOUR HOUSE DO NOT DRAW A MAP

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