Blue Ridge Electric Membership Corp. - Energies - Residential Service Application

Residential Service
Please complete all spaces below to apply on-line.

Name on Account:
First Name:
Last Name:
E-mail Address:
Home Phone:	- -
Work Phone:	- -
Billing Address:
City:
State:
Zip Code:	-
Street Address:
City:
State:
Zip Code:	-
Applicant's Place of Employment:
How Long?:
Nearest Relative Not Living With You:
First Name:
Last Name:
Relationship:
Telephone Number:	- -
Billing Address:
City:
State:
Zip Code:	-

Do you have an existing tank? Yes No
Do you own your own tank? Yes No
What type of fuel do you use? Fuel Oil K1 Kerosene Propane
If propane, what size is your tank? 200 lb. cylinder 420 lb. cylinder 250 gallon tank 325 gallon tank 500 gallon tank 1000 gallon tank
Location of tank: Above Ground Underground
Location (directions to home site):

A DEPOSIT MAY BE REQUIRED IF YOUR ACCOUNT CANNOT BE ESTABLISHED THROUGH A CREDIT CHECK. A BLUE RIDGE ENERGIES REPRESENTATIVE WILL CONTACT YOU IMMEDIATELY SHOULD THERE BE A QUESTION IN ESTABLISHING YOUR ACCOUNT.
Comments:
Blue Ridge Energies appreciates your business and looks forward to serving you. BY SUBMITTING THIS FORM, I CERTIFY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. BLUE RIDGE ENERGIES, LLC IS AUTHORIZED TO MAKE ANY AND ALL INQUIRIES NECESSARY FOR ACTION ON THIS APPLICATION. I HEREBY INDEMNIFY BLUE RIDGE ENERGIES, LLC AND ITS AGENTS FROM ANY LIABILITY RESULTING FROM THEIR CREDIT SURVEY. I UNDERSTAND THAT BLUE RIDGE ENERGIES, LLC TERMS ARE NET DUE - 30 DAYS AFTER DELIVERY OF PRODUCT AND AGREE TO MEET THESE TERMS IF CREDIT IS EXTENDED. BY SUBMITTING THIS FORM, I ALSO AGREE TO PAY ANY AND ALL FINANCE CHARGES, PENALTIES, OR COURT COSTS RESULTING FROM THIS ACCOUNT BEING DELINQUENT. A FINANCE CHARGE OF 1 �% PER MONTH, WHICH IS AN ANNUAL PERCENTAGE RATE OF 18% WILL BE ADDED ON THE REMAINING UNPAID BALANCE OVER 30 DAYS OLD.

Residential Service