Services Requested*

Furnace oil Sales & Delivery
Propane Sales & Delivery
Service
HVAC - Sales & Installation
Fireplace - Sales & Installation
Card Lock Services

Business Name: (legal name)*

Operating As:

Type of Business:*

Parent Company: (legal name)*

Business Address*

Street Address Address Line 2 City Province Postal Code

Is your Billing Address different to your Business Address?*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is your Shipping Address different to your Business Address?*

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Established Business Reference #1

Trade Reference #1*

Contact Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Established Business Reference #2

Trade Reference #2*

Contact Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

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 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 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 the 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: To provide our customers with petroleum and propane products and home heating services and to bill for those products and services To respond to customer inquiries and about energy use and billing To prevent fraud with respect to our customers and employees To meet legal and regulatory requirements 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 the information that we have collected and to request amendments to information about your company to ensure its accuracy and completeness. Please feel free to call us at (226) 314-2445 if you have any concerns about the collection and use of your company 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.

Authorized Contact*

Title*

Email*

Phone*

Name

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