Services Requested:

Applicant Name: (in full)

Date of Birth (YYYY/MM/DD/)
-- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 / -- 01 02 03 04 05 06 07 08 09 10 11 12 / -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Co-applicant Name: (in full)

Date of Birth (YYYY/MM/DD)
-- 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 / -- 01 02 03 04 05 06 07 08 09 10 11 12 / -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Address:

City/Town
,

Postal Code

Delivery Address: (if different than above address)

City/Town
, ON

Postal Code

Previous Address: (if at present address less than one year)

City/Town
,

Postal Code

Employer

Address

Position

How Long

Previous Employer (if less than 1 year)

Address

Position

How Long

Employer (Co-Applicant)

Address

Position

How Long

Other Credit References

VISA:    Expiry Date:

MasterCard:    Expiry Date:

THE UNDERSIGNED CERTIFIES THE ABOVE INFORMATION TO BE TRUE AND AFFIRMS THAT ANY CREDIT GIVEN IS EXTENDED UPON THE BASIS OF SUCH INFORMATION. The applicant consents to BRYAN'S FUEL making such investigations, at any time, of the applicant's credit standing and/or personal information in connection with the credit hereby applied for or any renewal or extension thereof and to the disclosure of any credit information concerning the undersigned to any credit reporting agency. The undersigned agrees to pay a monthly credit charge composed of interest only at the rate of 1 1/2% per month (18% per annum nominal) compounded monthly on any overdue balance. BRYAN'S FUEL may cancel this agreement or vary the terms hereof and the customer shall remain responsible for all indebtedness. Continued use of this charge account by the customer following notification that the terms have been varied will be deemed acceptance by the customer of such new terms as of the effective date mentioned on the notice both with respect to indebtedness incurred subsequent to such date and unpaid indebtedness at such date. The undersigned agrees that any payments are to be applied firstly on account of carrying charges and secondly on account of the purchase price of merchandise in order of purchase. Any payment which is returned by the financial institution shall carry a $25.00 penalty.

BRYAN'S FUEL is committed to protecting the privacy of personal information you have provided in compliance with the Personal Information Protection and Electronic Documents Act. BRYAN'S FUEL uses the information we collect for the following purposes:

1. To provide our customers with petroleum and propane products and home heating services and to bill for those products and services
2. To respond to customer inquiries and about energy use and billing
3. To prevent fraud with respect to our customers and employees
4. To meet legal and regulatory requirements
5. To assist in the collection of accounts

Because of the structure of the energy market in Ontario it may be necessary to share your consumption and billing information with regulatory agencies. You have the right to request access to your personal information that we have collected and to request amendments to personal information about you to ensure its accuracy and completeness. Please feel free to call us at (519) 941-2401 if you have any concerns about the collection and use of your personal information by BRYAN'S FUEL.

The above information is given for the purpose of obtaining credit and shall be regarded as true and correct. I/We hereby acknowledge the terms of payment and agree to abide by them.

Please note: Your IP address and the time is being recorded with the data submitted as your signature of acceptance.

Applicant:

CoApplicant:

Email: