Applicant Name*

First Last

Date of Birth*

Email*

Do you have a Co-Applicant?*

Co-applicant Name*

First Last

Co-applicant Date of Birth*

Services Requested*

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

Phone*

Alternate Phone

Do you own or rent?*

Landlord Name*

First Last

Landlord Phone*

Address*

Street Address Address Line 2 City Province Postal Code

Is your delivery address different from above?

Delivery Address*

Street Address Address Line 2 City Province Postal Code

Have you been at your current address less than one year?*

Previous Address*

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

Employer*

Employer Address*

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

Employment Position*

Length of Employment*

Previous Employer*

Previous Employer Address*

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

Position*

Length of Employment*

Co-Applicant Employer*

Co-Applicant Employer Address*

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

Co-Applicant Employment Position*

Length of Employment*

Legal Disclaimer

BY SUBMITTING THIS FORM, THE APPLICANT(S) CERTIFIES THE ABOVE INFORMATION TO BE TRUE AND AFFIRMS THAT ANY CREDIT GIVEN IS EXTENDED UPON THE BASIS OF SUCH INFORMATION. The applicant(s) consents to BRYAN'S FUEL making such investigation, at anytime, 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 at the rate of 1 1/2% per month (19.6% per annum) 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 the 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 incur a Returned Item Fee, currently $25.00, but subject to change.

BRYAN'S FUEL is committed to protecting the privacy of personal information you have provided in compliance with the Personal Information and Electronic Documents

Act. BRYAN'S FUEL uses the information we collect for the following purposes:

a) to provide our customers with petroleum and propane products and home heating services and to bill for those products and services b) to respond to customer inquiries and about energy use and billing c) to prevent fraud with respect to our customers and employees d) to meet legal and regulatory requirements e) 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 concerns about the collection and use of your personal information by BRYAN' S FUEL.

Name

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