Residential Application

DOC - Daigle Oil Co.

Referring Customer Account Number (If Applicable)

First Name *

Last Name *

SSN *

Date of Birth *

Billing Address *

City *

State *

Zip *

Year(s) At This Address?*

Home / Cell Phone *

Work Phone

Employer

Year(s) There

Annual Salary *

Housing Info *

Own / Buying Home Renting

Email *

Confirm Email *

Billing Documents: Please select one*

Email Documents- I give DOC authorization to set my account up on paperless billing. I understand I will receive billing documents and delivery slips by email only.

Mail Documents - I understand DOC will leave a delivery slip each time a delivery is made. If the delivery slip is priced, this is considered the invoice by which to pay from. If it is not priced, DOC will send a billing document by US mail. If the account is a DOC CARD account only, statements will be sent by US mail.

Home Fuel Account DOC Charge Card Only

If you would like a DOC Charge Card for purchases at our DOC's Place Service Stations, please indicate how many cards you need. Issuance is subject to approval.

How many cards do you need?

Fill Pipe Location: *

Front of House Back of House Left Side Right Side

Driver Instructions

What size is your fuel or propane tank? (Gallons) *

Approximate Annual Fuel Usage In Gallons*

Estimated gallons remaining? *

Additional source of heat?*

Yes No

If approved, when would you like your first delivery? *

How many gallons do you want delivered? *

If other, enter amount

Co-Applicant Present

Terms & Conditions: All information provided above is true to the best of my/our knowledge. I/we authorize you or any credit reporting agency employed by you to investigate the references herein listed or any other type of information stated above to determine my/our qualification(s) for a credit account. If credit is hereby granted, I/we agree to pay the amount in full within thirty (30) day credit terms. A finance charge of 1 ½% per month (annual percentage rate of 18%) will be assessed on all accounts unpaid in thirty days following the due date. Non compliance with credit terms may result in the disruption and/or termination of fuel deliveries. In the event of default of payment, I/we agree to pay any and all costs of collection including, but not limited to, reasonable attorney fees.

By checking this box, I acknowledge that I have read the above statements and agree to the terms and conditions *

* Applicant Signature
Typed names are equivalent to handwritten signatures and are legally binding

DOC - Daigle Oil Co.

RESIDENTIAL DOC APPLICATION

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