Call Mansfield Oil & Energy Co., Inc  @ 1-508-339-4473                                                                   

                                                Credit Account  Application  &  Agreement 

Account Information

Name ________________________________________________Date________________

Delivery Address___________________________________________________________

Mailing Address (if different from Delivery Address)

_________________________________________________________________________

Phone (H)________________(W)_______________(C)____________Email____________

Nearest Cross Street________________________________________________________

What type of heat do you use? Heat #2 and/or Air or both. What is it for _____Heat____Heat/Hot

# of tanks ___________size_____________inside or outside______

age of tank _______amount in tank now __________

Account Type:

________Will call customer – I will call you when I need a delivery.  I understand that an emergency fee and or  furnace boiler start up fee may apply for emergency deliveries.

_______Automatic Delivery Customer – You may automatically  deliver to my home to fill my tank. I will make payment within 20 days and agree to have a current credit card on file in the event the balance is not paid in full in 20 days, you may charge my credit card. As an automatic customer I understand that I will not be charged an emergency delivery fee should I run out of oil if my account balance is up to date. (Automatic Delivery must also complete the credit authorization form).

Service requested:

___I would like to schedule a fuel delivery:  _______fill or ________150 gallons.  (150 gal minimum)

___I would Like to be called  to schedule an annual tune – up.

___I would like to be called to schedule service on my equipment, I am experiencing some problems.

       Briefly Describe problem________________________________________________

Payment Arrangement

_____I will give the delivery driver and/or the service technician a check, or credit card upon Delivery/service.

_____Please charge my credit card on file for deliveries/service. (Customer must complete the credit card authorization form).

Customer Signature                                   Print name                                              Date

                                                                         Please Print & Sign as indicated – If you have Any questions – Please feel free to call.

                                                                                                         945 East  Street, Mansfield, MA 02048 1-508-339-4473