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Residential Credit Application

To apply for residential credit with Deiter Bros., either complete this online form and click the Submit button or download this Residential Credit Application and mail or fax it back to us.

The red * indicates required fields.

   
BILLING INFORMATION
* First Name:
Middle Initial:
* Last Name:
* Address:
* City:
* State:
* Zip:
* Date of Birth:
* Social Security No:
* Home Phone:
Cell Phone:
* Email Address:
* Verify Email:
 
List Additional owner's name (spouse, partner, etc.) If none, please leave blank.
First Name:
Middle Initial:
Last Name:
Date of Birth:
Social Security No:
 
DELIVERY ADDRESS
(if same, please leave blank)
Address:
City:
State:
Zip:
* Do You Own or Rent?:
* How Long at Address:
If Renting, When Does Lease Expire:
* Is This a Business or Apartment?:
* If Renting, Does Landlord Pay for Service?:
If yes, please provide:
Landlord Name:
Phone Number:
Address:
 
EMPLOYER(S)
(please list for each owner listed above)
* Employer Name:
* Phone Number:
* How Long?:
Employer Name:
Phone Number:
How Long?:
If paying by ACH please provide the following, otherwise leave blank.
Bank Name:
Account Number:
Routing Number:
Type of Account:
If paying by credit card please provide the following, otherwise leave blank.
Credit Card Type:
Credit Card Number:
Expiration Date: Month:       Year:
Credit Card ID:
  How do I find my card identification number?
* Name of Relative Not Living With You:
* Relation:
I/WE CERTIFY THAT ALL OF THE INFORMATION ON THIS FORM IS CORRECT. I/WE HAVE READ AND FULLY UNDERSTAND AND AGREE TO YOUR CREDIT POLICY. INTENDING TO BE LEGALLY BOUND, I/WE AGREE TO THESE TERMS IN CONSIDERATION OF CREDIT BEING EXTENDED TO ME/US. I/WE CERTIFY THAT I/WE HAVE THE AUTHORITY TO EXECUTE THIS AGREEMENT ON BEHALF OF ALL OWNERS OF THE PROPERTY DESCRIBED ABOVE. I/WE AUTHORIZE YOU TO INVESTIGATE THE REFERENCES LISTED HERE AND TO REQUEST INFORMATION FROM CREDIT REPORTING AGENCIES.
* Name:
 
DELIVERY INFORMATION
Previous Fuel Company (if known):
* Type of Fuel:
* Tank Size:
* Automatic Delivery:           Interval:
(Automatic delivery is convenient and costs you nothing. If interval is not specified, deliveries are made according to degree day methodology.)
* Where is the Location of Your Fill Pipe or Tank?: (If a clock were placed over the top of your home or office, which number best describes the location of the fill pipe or tank, with 12 being the rear and 6 being the front?)
First Delivery Date:
 
IMPORTANT: If this is the first time we are delivering to this address, someone must be home for our driver to inspect the tank, (1st delivery only). You can waive this requirement by acknowledging that your tank is installed and operating properly and there are no signs of deterioration or leaks. All connecting piping is iron pipe. There is no PVC piping.

I would like to waive the tank inspection requirement. I acknowledge that my tank is in proper working order and complies with the specifications listed above.
Name:
Date:
 
Special Delivery Instructions:
 
SERVICE INFORMATION
* Would You Like a Maintenance Agreement?:
* Is Your Heating System a Furnace or Boiler?:
* Do you know the approximate age of your heating system?:
* Do you want to setup an appointment to have your heating system cleaned and tuned up?:
If yes, what would be a good time for you?:
* Do we have your permission to conduct a credit check?:
 
 

 
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