RESIDENTIAL ACCOUNT SETUP FORM AND CREDIT APP - Saveway Petroleum

860-779-2500

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How did you hear about us? *

Will you need to lease a tank or tanks? *

Would you like to apply for credit terms? *

Primary Applicant Name *

First

Last

Primary Applicant Email *

Primary Applicant Phone *

Primary Applicant Date of Birth *

Primary Applicant Address Information

Current Address *

Address Line 1

City

State

Zip Code

Less than a year at this address? *

Yes
No

How long at this address? *

months *

Primary Applicant PREVIOUS ADDRESS (if less than a year at previous address)

Address Line 1

Address Line 2

City

State

Zip Code

Will propane delivery be made to a different address? *

Yes
No

Delivery Address *

Address Line 1

City

State

Zip Code

Tank Size *

Tank Serial Number (N/A if requesting a leased tank) *

Do you have a second delivery address to add? *

Yes
No

2nd Delivery Address *

Address Line 1

City

State

Zip Code

Tank Size *

Tank Serial Number (N/A if requesting a leased tank) *

Do you have a third delivery address to add? *

Yes
No

3rd Delivery Address *

Address Line 1

City

State

Zip Code

Tank Size *

Tank Serial Number (N/A if requesting a leased tank) *

More than 3 Delivery Addresses?

You can provide additional delivery addresses to our customer service representative when we are ready to set up your account.

Primary Applicant Employment Information

Primary Applicant Employer *

Primary Applicant Position/Job Title *

Primary Applicant Employer City, State *

Primary Applicant Employer Phone *

Primary Applicant Length of Employment *

Length of Employment (months) *

Primary Applicant Financial References

Bank - Name *

Bank - Phone *

Bank - City/State *

Landlord or Mortgage Company - Name *

Landlord or Mortgage Company - Phone *

Landlord or Mortgage Company - City/State *

Utility Company - Name *

Utility Company - Phone *

Utility Company - City/State *

IMPORTANT NOTICE TO CREDIT APP CUSTOMER *

By signing below, you agree to the following

The information supplied is accurate as of the date shown;
An investigation of all statements or credit data herein and release of such information to DCC Propane, LLC or any of its subsidiaries, from any and all sources is authorized;
A release is granted to all parties from all liability for any damage that may result from furnishing information to you;
If applying for credfit, to recognize that your individual credit history may be a factor in the evaluation of this application.
If applying for credfit, you consent to and authorize the use of any external credit reporting information utilized by DCC Propane, LLC or any of its subsidiaries, from time to time as may be needed; and
Authorization is granted to disconnect my gas line from my current supplier’s tank; move current supplier’s tank and replace with DCC Propane tank and where applicalble, to transfer propane from current supplier’s tank to DCC Propane’s tank. I HEREBY GRANT A SECURITY INTEREST IN THE TANK(S) DESCRIBED ABOVE TO DCC Propane, LLC TO SECURE ANY AND ALL AMOUNTS WHICH MAY BECOME DUE ON MY ACCOUNT. I AGREE TO BE RESPONSIBLE FOR ANY BALANCE WHICH IS DUE OR MAY BECOME DUE ON THIS ACCOUNT. Unless otherwise required by law, all sales are final. No cash refund will be provided and any credits on account will be applied to the next propane delivery or can be transferred to another account. I further agree to have my account set up on Auto Route which means deliveries will be made without the need for me placing an order.

Date / Time *

Date

Time

Do you have a Co-Applicant? *

Yes
No

CO-APPLICANT INFORMATION - All fields are required to have a co-applicant on the account.

Co-Applicant Name *

First

Last

Co-Applicant Employer *

Co-Applicant Position/Job Title *

Co-Applicant Employer Street Address, City, State, Zip *

Co-Applicant Employer Phone *

Co-Applicant Length of Employment *

Co-Applicant Length of Employment - months *

IMPORTANT NOTICE TO CUSTOMER - Co-Applicant *

By signing below, you agree to the following

1. The information supplied is accurate as of the date shown; 2. An investigation of all statements or other credit data herein and release of such information to DCC Propane, LLC or any of its subsidiaries, from any and all sources is authorized; 3. A release is granted to all parties from all liability for any damage that may result from furnishing information to you; 4. To recognize that your individual credit history may be a factor in the evaluation of this credit application; and, 5. Consent to and authorize the use of any external credit reporting information utilized by DCC Propane, LLC or any of its subsidiaries, from time to time as may be needed.

Co-Applicant Signature Date / Time *

Date

Time

Account Setup Date/Time *

Date

Time

SAVEWAY PETROLEUM

235 Westcott Rd, Danielson, CT 06239
(860) 779-2500

Monday	8:00 AM - 4:30 PM
Tuesday	8:00 AM - 4:30 PM
Wednesday	8:00 AM - 4:30 PM
Thursday	8:00 AM - 4:30 PM
Friday	8:00 AM - 4:30 PM

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