Personal Home Heat Credit Application - Dysart's Restaurant and Truckstop in Bangor, ME

Thank you for your interest in heating oil from Dysart’s. Please fill out the application below and a representative will be in touch with you soon!

Full Name*
First Last
Date of Birth*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Physical Address (if different from mailing)
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone*
Email Address
Address (if less than 2 years at current address)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Employer*
Employer Address*
Street Address Address Line 2 City State ZIP Code
Occupation*
How long have you been employed?*
Monthly Income*
Name of nearest relative not living with you*
First Last
Relative's Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Name of personal friend*
First Last
Personal Friend's Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Previous Fuel/Oil Suppliers Name
(If applying for a heating oil account)
Previous Fuel/Oil Suppliers Address*
Street Address Address Line 2 City State ZIP Code
Oil Tank Size (choose one)*
- 275 gallon
- 330 gallon
(If applying for a heating oil account, please select one)
Is your tank an inside tank or outside tank?
- Inside
- Outside
(If applying for a heating oil account, please select one)
What type of heating oil do you want prefer?
- #2
- Blend
- Kero
(If applying for a heating oil account, please select one)
For heating oil accounts, please provide directions to your home and a description of the property
Bank Name
Checking?
- Yes
- No
Savings?
- Yes
- No
Bank Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Terms*
- Station/Shop: Full payment within 15 days of statement date
- Kard Gard: Full payment within 7 days of invoice date
- Wholesale: 1% discount within 10 days or full payment on the 11th day
- Lubricants: Full payment within 30 days from statement date
- Home Heat: Full payment within 10 days of invoice date
- Dysart's Credit Card: Full payment within 30 days of statement date
Please select one below to choose desired account type and to acknowledge terms.
I/We fully understand the credit terms and agree to the proper payment in consideration of extended credit and that all information on this form is true and correct. I/We agree that the bank and references are provided to allow Dysart's to contact them to use in its credit decision and that Dysart's may request further credit information from a credit reporting agency.
In the event that our account becomes delinquent, I/We also agree to pay all collection costs and legal fees should our account be presented for collection with an authorized agency or attorney.
I/We do hereby personally, jointly and severally, guarantee payment of this account at all times.
Signature/Title*
Date*
Signature/Title
Date

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