"*" indicates required fields 1Service Info2Applicant Info3Final Info CompanyThis field is for validation purposes and should be left unchanged.Prior to submitting any application to MX Fuels and Propane for processing, please be sure your credit report is available for review. If you have a freeze or hold on your report, we are unable to process your application until it is lifted. What type of customer are you* Residential Commercial Residential Fuel products you need* Propane Heating Oil Kerosene Diesel Fuel Commercial Fuel products you need* Propane Heating Oil Gasoline Kerosene Diesel Fuel Existing Propane Appliances* Furnace Boiler Space Heater Water Heater Fireplace Dryer Cooking/Stove Generator check all that applyNotice Due to the high demand for propane, we are unable to accept any new generator only propane customers at this time. If you wish to contact us with questions, please feel free to contact us at 1-800-840-0645. Notice Due to the high demand for propane, we are unable to accept any new generator and cooking stove only propane customers at this time. If you wish to contact us with questions, please feel free to contact us at 1-800-840-0645. Notice Due to the high demand for propane, we are unable to accept any new cooking stove only propane customers at this time. If you wish to contact us with questions, please feel free to contact us at 1-800-840-0645. Do you own or rent?* Own Rent Location If location is rentedName of Property Owner/Landlord* First Last Account # if applicableLandlord Phone*Landlord Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Afghanistanร land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCรดte d'IvoireCroatiaCubaCuraรงaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRรฉunionRomaniaRussian FederationRwandaSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTรผrkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country PROPANE EQUIPMENT REQUIREDTank Size/Qty200lb420lb330lb500lb1000lbAdd the number of tanks you need for each under the tank size.Est. Gallons/YearSpecial InstructionsTERMS & CONDITIONS* I acknowledge that I have read and understand the above terms & conditions as outlined in this agreement between MX Petroleum Corp. and me.Credit Approval/Account Set Up All propane accounts must be credit-approved. An authorized agent of MX Petroleum Corp. (hereafter referred to as MX) will use the information provided to verify credit through an outside credit reporting agency. The credit application will remain on file for the duration of your time as a customer. All information provided is for MXโs use only and will not be shared with any outside parties. Please be advised that all credit-approved propane accounts will be set up with automatic delivery. MX is not responsible for product run-out for accounts not enrolled in our automatic delivery option. Customers choosing to call in for their deliveries must be sure to always monitor their tank levels and contact MX to request a delivery when needed. MX will schedule all call-in deliveries on the first available day possible. MX reserves the right to remove your account from automatic delivery at any time if you fail to abide by the terms and conditions outlined in this agreement. If, for any reason, you choose to have your account removed from automatic delivery, it is required that you submit a written request to our office at PO Box 638, Massena, NY 13662. General Terms & Conditions of Payment MX Petroleum Corp. requires payment in full within 10 days of your delivery or before your next delivery, WHICHEVER COMES FIRST. No deliveries (call-in or automatic) of any product will be made if there is an outstanding balance owed on account. To the extent that purchases remain unpaid beyond agreed terms, MX will assess finance charges or interest, whichever is applicable, at the maximum rate allowable under NY State Law. Payments received will be applied to any finance charges or interest owing on the account first, with any remaining credit to be applied towards the aging balance. (MX. does not accrue interest upon interest). If payment is not received within 30 days from the date of delivery, then you will receive written and/or verbal notice that the tanks will be picked up due to non-payment. Any costs and/or fees accrued due to tank pick up will be the responsibility of the customer. If full restitution is not made on purchases within 60 days and no other payment agreement can be reached, Seller reserves the right to charge credit card on file or perform an E.F.T. payment using your bank information to secure the balance past due on account. If this option is not available, MX also reserves the right to proceed with collections through a 3rd party agency or take civil action against you in a court of law. Any expense accrued by MX while attempting to collect a debt owed, including but not limited to reasonable attorney fees and court costs, must be reimbursed to MX by you, the customer. Automatic Payment Terms & Conditions Any customer enrolled in automatic payments with MX recognizes the following: MX desires the flexibility to collect payments for business transactions through the Automated Clearing House Network. The customer agrees to grant MX such flexibility. Automatic Payment Customers (1) Authorize MX to collect payments for business transactions by their specified method EFT or automatic payment processing to a specified debit/credit card provided, (2) Certify that they have provided MX with a valid depository financial institution, (3) Directs that all such electronic funds transfers or automatic debit/credit card payments be made as specified (4) has provided all necessary documentation to process payments via their selected method. Customer shall receive notice of invoices and/or debits in such form as requested and at such time as established by MX. If any debit to the Customerโs account is dishonored by the bank (for whatever reason), MX shall be entitled to recover from the Customer all charges imposed by the bank. Any such occurrence of dishonored items may result in the termination of the customerโs credit status. Lock-In Pricing Terms & Conditions Customer understands that the โLock Inโ period is valid for the period shown on the Lock in Agreement. At the end of the Lock In period, your account will automatically revert to market pricing. By choosing the โLock Inโ Price Option, you understand that you will be bound by the following: Locking in your price will not move up or down If at the end of the โLock Inโ period, or upon earlier termination of this agreement by the customer, MX will have the right to assess and collect from the customer a charge equal to the number of committed gallons not purchased multiplied by the amount of your โLock Inโ price. A customer is making their best efforts to live up to the spirit of this agreement, and those who purchase all their fuel requirements from MX will not be penalized should their purchases fall short of the committed gallons due to warmer weather or improvements to their heating system. The โLock Inโ pricing information listed on your โLock Inโ Agreement is effective for the date range as specified on the agreement; at the end of the โLock Inโ period listed, your pricing will automatically revert to market pricing. If the number of gallons purchased is greater than the number of gallons committed to in this โLock Inโ Agreement, all additional gallons, more than your committed gallons, will be billed at market price. Should you decide to cancel your purchases or if your deliveries are stopped for any reason, such as non-payment of balance owed or changing providers during the contract period, you will be in default and may be subject to penalties. Penalties may consist of any additional costs, such as collection costs and attorney fees, incurred by MX due to your cancellation. Furthermore, you will be subject to a $150.00 (plus applicable taxes) tank pick-up fee and a $1.00 per gallon restocking fee. MX Propane Tank and Monitor Usage / Applicable Rental Fees and Minimum Purchase Requirements By signing this contract, you are agreeing to a minimum yearly (January 1st โ December 31st) purchase requirement described below. These requirements will take effect beginning January 1st of the year following the contract date. Any MX Petroleum Corp.-owned Propane Tanks(s) or equipment set at a customerโs location remains the property of MX.>/strong> ONLY MX Petroleum Corp. is permitted to fill, perform pump outs, or move MX-owned tank(s)/equipment. Customers in violation of these terms may be subject to additional fees, pending a review by MX. Furthermore, customers are responsible for any damage to MX tank(s)/equipment, except for normal wear and tear, and any fees assessed because of failure to abide by these terms. MX may charge a yearly tank rental fee or a delivery fee per tank. In the event a customer fails to meet the minimum purchase requirements, MX reserves the right to charge a yearly rental fee of $100.00 per tank for the shortfall of gallons. Account reviews will be in the month of January, and any applicable rental fees will be billed at this time. Required Purchase Requirement – 200 lb Tank โ 50 Gallons Per Year – 330 Gallon Tank- 350 Gallons Per Year – 420lb Tank โ 100 Gallons Per Year – 500 Gallon Tank โ 500 Gallons Per Year – 1000 Gallon Tank โ 1000 Gallons Per Year Propane Tank Monitor Usage Fees: Customers establishing propane service through MX that will be utilizing MX propane tanks will have the option of having a monitor system installed on their tank(s) for a yearly fee, which is determined based on the customerโs yearly propane volume and the number of monitors to be installed at the location. MX reserves the right to remove a monitor from a customerโs location at any time if the customer fails to maintain an acceptable credit rating with MX, misuse or damage of MXโs equipment, or in the event the customer fails to meet the minimum yearly gallon purchase requirements. Below is a breakdown of the Monitor Usage Fees per yearly propane volume requirements: < 500 Gallons per Year - $75.00 per year for 1st monitor / $50.00 per year for each additional monitor 500 โ 1000 Gallons per Year – $50.00 per year for 1st monitor / $ 35.00 per year for each additional monitor 1001 Gallons per Year or more – No Charge for 1st monitor / $25.00 per year for each additional monitor *Owners/Landlords of rental properties: In the event you are the legal property owner but use the delivery location as a rental property, you are responsible for notifying us of a change in tenant at said location. Any deliveries made to the location without an active supply agreement on file for the current tenant will be billed to the property owner/landlord. Any unpaid product remaining in the tank at the time the tenant vacates the location will be made available for purchase to you; in the event you decide to opt out of purchasing this unpaid product, MX reserves the right to perform a pump out to recoup its costs. In the event the tenant fails to pay any balance due on his/her account, resulting in the need for a tank pick up, MX will contact the property owner/landlord to allow them the opportunity to settle the debt owed and avoid a tank pick up. The property owner/landlord must understand that no deliveries will be made to their property in the event their tenant owes an outstanding balance. **If you are not the legal owner of the property on which the tank is set (tenant), you are required to pay a $150 security deposit. MX reserves the right to retain this deposit in the event of termination/default of contract** Termination/Default of Contract: โข Fails to maintain an acceptable credit rating with MX or is otherwise in arrears on any bill due to MX or its service representatives; (MX does not accept C.O.D. Propane Accounts. โข Misuse and/or damage of MXโs equipment โข Fails to meet minimum yearly gallon purchase requirements In the event of termination of service, whether requested by MX or the customer, a pick-up fee of $150.00 per delivery location plus a restocking fee of $1.00 per gallon for any product remaining in tanks at the time of pick-up will be charged to your account. If any of these fees apply, the customer agrees to pay these fees within 10 days from the date of tank pick up. BUSINESS INFORMATIONCustomer Name*DBABilling Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Afghanistanร land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCรดte d'IvoireCroatiaCubaCuraรงaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRรฉunionRomaniaRussian FederationRwandaSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTรผrkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Contact Name*Phone*FaxEmail* Federal Tax ID*Principle Officer/Partner 1*Title*Social Security#*Principle Officer/Partner 2TitleSocial Security#Bank ReferencesBank Name/Branch*Account #*Contact*Phone*FaxTrade ReferencesOil SuppliersName*Contact*Phone*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OTHER TRADEName*Contact*Phone*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Afghanistanร land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCรดte d'IvoireCroatiaCubaCuraรงaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRรฉunionRomaniaRussian FederationRwandaSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTรผrkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Name*Contact*Phone*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Afghanistanร land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCรดte d'IvoireCroatiaCubaCuraรงaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRรฉunionRomaniaRussian FederationRwandaSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTรผrkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Delivery/Service Information (All credit approved propane accounts will be set up on automatic delivery)Consent* I agree with the below*Please note that if multiple locations are being serviced by MX Petroleum Corp. this agreement will be used as a blanket agreement to cover all propane tanks in use by the customer at all locations served by MX Petroleum Corp.Delivery Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Select one* Own Rent Temporary Jobsite Other If location is rented or temporary jobsite: Name of Property Owner/Landlord*Account # if applicableAccount # if applicableLandlord Phone*Landlord Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Afghanistanร land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCรดte d'IvoireCroatiaCubaCuraรงaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRรฉunionRomaniaRussian FederationRwandaSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTรผrkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country MX PETROLEUM CORP. GENERAL TERMS AND CONDITIONS* I agree to the below.Where possible, BUYER shall agree to MX Petroleum Corp.โs (Herein referred to as SELLER) Standard Agreement prior to delivery of product from sellerโs truck. TITLE: Title and risk of loss, including without limitation, risk of damage, deterioration and/or evaporation, passes from seller to BUYER when the product passes the flange or spout between SELLERโS delivery line and BUYERโS receiving connection or equipment. Whether truck, rail car, barge or other receiving equipment. CREDIT: SELLER will issue a credit limit at its discretion after receiving and examining references and other which may be requested for the purpose of establishing credit limits. SELLER reserves the right at any time to withdraw or adjust the credit limit. If required by SELLER, the BUYER will issue security in a form and amount acceptable to the SELLER or provide a Personal Guaranty. PAYMENTS: Credit terms of payment will be set upon completion and review of this application and will be subject to credit limits assigned. To the extent that purchases remain unpaid beyond agreed terms; SELLER will assess finance charges or interest, whichever is applicable, at the maximum rate allowable under State Law. Payments received will be applied to any finance charges or interest owing on the account first, with any remaining credit to be applied towards the aging balance. If payment is not received within the allotted terms, SELLER the right to revoke charge status. If full restitution is not made on purchases within 60 days and no other payment agreement can be reached, SELLER reserves the right to charge any credit card on file or perform an E.F. T. payment using BUYERโS bank information to secure the balance past due on your account. If this option is not available, SELLER also reserves the right to proceed with collections through a 3rd party agency or take civil action against BUYER in a court of law. Any expense accrued by SELLER while attempting to collect a debt owed, including but not limited to reasonable attorneyโs fees and court costs, must be reimbursed to SELLER by you the BUYER. TAXES: All taxes, duties, fees or any other charges (collectively โTaxesโ) that are imposed or assessed by any Federal, State, County or Local Government or Agency in respect to the purchased product will be paid to the SELLER by the BUYER. If BUYER is exempt from any taxes, fees or charges, it must provide the Seller with a proper Exemption Certificate prior to lifting any product. Failure to timely provide the proper Exemption Certificate shall automatically subject the BUYER to pay such tax, fee or charge, include any applicable interest, penalties, and/or consequential costs or fees imposed upon Seller as a result of such failure. FORCE MAJEURE: Neither the SELLER nor BUYER is liable for failure to timely perform any of his obligation under this contract, if failure was due to impediment beyond the partyโs control, including but not limited to National and International markets in fuel supply and production. The party-claiming impediment shall give facsimile notice to the other party prior to delivery time and date. The party-claiming impediment shall use all reasonable and diligent efforts and delivery shall be suspended only so long as the impediment remains, unless the parties agree to terminate their mutual obligation. MX PETROLEUM CORP. GENERAL TERMS AND CONDITIONS* I agree to the below.CLAIMS: Any controversy or claim regarding the quality of purchased product will be Time-Barred unless by the BUYER in writing to the Seller within ten (10) days of purchase date. ASSIGNMENT: The BUYER cannot assign any of its product contract rights or obligations without the prior written consent of the SELLER. Seller may assign the product contract rights for the purpose of financing to its banks and/or financial institutions. WAIVER: Any failure of the SELLER to enforce any provision shall not be deemed a waiver of the right to enforce such provisions in the future. WARRANTY: Except as to quality, SELLER makes no warranties, expressed or implied, with respect to the merchantability of product or otherwise. The warranty of fitness for a particular purpose is expressly disclaimed. In no event shall Seller be liable for incidental, consequential or punitive damages.PRIMARY APPLICANT INFORMATIONName* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Site Address (if different) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Afghanistanร land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCรดte d'IvoireCroatiaCubaCuraรงaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRรฉunionRomaniaRussian FederationRwandaSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTรผrkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country # of Years at This Address*Phone*CellEmail* Do you wish to receive invoices via email?*YesNoDo you wish to receive statements via email?*YesNoSocial Security #*Date of Birth* Month Day Year Drivers License #*Drivers License State*Drivers License Expiration Date* Month Day Year I am Retired On Disability Employer*Years at Employer*Work PhoneWork Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Afghanistanร land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCรดte d'IvoireCroatiaCubaCuraรงaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRรฉunionRomaniaRussian FederationRwandaSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTรผrkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Is there a Co Applicant?* Yes No CO APPLICANTCo Applicant Name* First Last Co Applicant Mailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Co Applicant PhoneCo Applicant CellCo Applicant Email Co Applicant Social Security #*Co Applicant Date of Birth* Month Day Year Co Applicant Drivers License #*Co Applicant Drivers License State*Co Applicant Drivers License Expiration Date* Month Day Year Select if Co Applicant is Retired On Disability Co Applicant Employer*Co Applicant Years at Employer*Co Applicant Work Phone*Co Applicant Work Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Afghanistanร land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCรดte d'IvoireCroatiaCubaCuraรงaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRรฉunionRomaniaRussian FederationRwandaSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTรผrkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country BANK INFORMATIONBank Name*Bank Account #*MORE INFORMATIONBank Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Afghanistanร land IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCรดte d'IvoireCroatiaCubaCuraรงaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRรฉunionRomaniaRussian FederationRwandaSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTรผrkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Directions to Site Address*Tank SizeTank Location*InsideOutsideDo you heat your hot water with oil?*YesNoDo you heat with an alternate heat source?*YesNoWhat do you heat with*If credit approved, do you wish to be on automatic delivery?*YesNoAdditional NotesAgree to Terms of Payment?* Yes, I AgreeGeneral Terms & Conditions* I agree to the below General Terms & ConditionsTERMS OF PAYMENT Credit terms are net ten (10) 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 to the MX Fuels Terms of Payment.