Residential Service Application

Name on Account
First Name
Last Name
Email Address
Home Phone
Work Phone
Place of Employment
How Long?

Billing
Billing Address
City
State
Zip Code

Service
Service Address
City
State
Zip Code

Nearest Relative Not Living With You
First Name
Last Name
Relationship
Phone Number
Mailing 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?
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):

PREPAYMENT 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:

1 + 2 = (sorry; we just need to make sure you are a human)

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 1.5% PER MONTH, WHICH IS AN ANNUAL PERCENTAGE RATE OF 18% WILL BE ADDED ON THE REMAINING UNPAID BALANCE OVER 30 DAYS OLD.