Application

Full Name:
Spouse Name:
Billing Address:
City:	State: Zip:
Site Address (if different):
City:	State: Zip:
Telephone:	# of Years at This Address:
Email Address:

	Customer	Spouse
Social Security #
Date of Birth:
Employer:
Years Employed:
Work Phone:
Work Address:
Directions to Find My Location:

Fuel Type:	Fuel Oil Kerosene 50/50 Mix
Tank Size:	Tank Location: Inside Outside

TERMS OF PAYMENT

Credit terms are net thirty (days) from delivery, subject to credit limits assigned by MX Fuels, A Division of MX Petroleum Corp. To the extent that purchases remain unpaid beyond agreed terms, Buyer will lose credit privileges and any special prices or discounts in place between Seller and Buyer, and Seller will assess late payment charges or interest, whichever is applicable, at the maximum rate allowable under state law. Buyer agrees to reimburse seller for all collection expenses, including reasonable attorney fees incurred in connection with the collection of delinquent amounts.

By checking below, I confirm that the information I have given in this application is complete and accurate. I authorize MX Fuels to verify this information, and I authorize the release of personal information listed above, solely for the use of credit verification by MX Fuels. I agree by the MX Fuels Terms of Payment.

Agree to Terms and Conditions: I Agree I Disagree