AlliedProGas - Account Application

IS THIS FOR PERSONAL OR BUSINESS USE*
Personal Use Business Use

TYPE OF SERVICE

TYPE OF SERVICE REQUESTED*
Propane Delivery Bulk Gas or Diesel Delivery Fleet Fuel Card Bulk Lubricants & Greese

*See our Application & Forms page for relevant exemption forms.

DO YOU RENT, LEASE OR OWN PREMISES LOCATED AT ADDRESS ABOVE?*
Rent Lease Own

ARE YOU A RESELLER?
No Yes

WILL YOU BE SUBMITTING A SALES TAX EXEMPT FORM OR RESEL CERTIFICATE?*
No Sales Tax Exempt Form Resel Certificate Both

APPLICANT INFORMATION

First

Last

APPLICANT'S EMAIL*

Enter Email

Confirm Email

BUSINESS PHONE #

OTHER PHONE

PHYSICAL ADDRESS*

Street Address

Address Line 2

City

State/Province/Region

Zip/Postal Code

Country

IS YOUR BILLING ADDRESS THE SAME AS ABOVE?*

Yes No

APPLICANT CREDIT REFERENCES (BANK OR OTHER OPEN ACCOUNT)

NAME OF BANK OR FIRM*

BANK OR FIRM ADDRESS*

ACCOUNT NUMBER*

ACCOUNT TYPE*

BANK OR FIRM TELEPHONE #*

RELEASE AND VERIFICATION OF INFORMATION/ AGREEMENT /SIGNATURE(S)

Permission is hereby granted to Applicant's creditors listed above to release the information requested by Allied Propane Service concerning such accounts. If Applicant is issued Fuel Access Cards, Applicant agrees to be bound by all of the terms and conditions set forth in Allied's Fuel Access Card Agreement, which are incorporated herein as though set forth in full. If Applicant charges purchases of products, equipment, and/or services, Applicant agrees to pay for such products, equipmennt, and/or services according to the following terms: Net 30 days on each invoice. A late payment charge of 2% per month will be applied to amounts not paid when due. In the event that collection and/or enforcement efforts are commenced by Allied, Customer shall pay to Allied its collection and legal expenses, including expert fees and attorney fees (both prejudgment and postjudgment). Customer agrees that the venue for any action arising out of the collection and/or enforcement shall be in the state of California. If Applicant is a Corporation, the Principals signing below agree to guarantee payment of any and all indebtedness of the Applicant to Allied and agree to be bound by the above terms and conditions. Applicant verifies that the information above is true and correct to the best of Applicant's knowledge.

DATE OF SIGNATURE*

NAME OF PRIMARY SIGNATORY

Last

First

Authorized Digital Signature