Your Phone Number *
Driver's License Number*
Rent / Own / Lease*
Landlord Phone Number*
Fill Pipe Location*
Number of Rooms*
Type of Burner*
Heat & Hot Water*
PLEASE HAVE YOUR SPOUSE COMPLETE THE FOLLOWING
Your Work Phone Number
Driver's License Number
NOTICE TO BUYER(S)
• You are entitled to a copy of this agreement and the information regarding your right to dispute billing errors
• You may at any time pay off the full unpaid balance
• Any changes to original account application set-up must be received by fax or mail
NOTE: Service contract goes into effect once heating system has been evaluated during annual cleaning. Pre-existing conditions are not covered.
Buyer(s) hereby acknowledges receipt of a true copy of this credit agreement and billing errors information.
NOTICE: I hereby authorize you or any credit reporting agency employed by you to investigate the references listed and any of the other information states about to determine my qualifications for a credit amount.
I certify that the information on this application is true and correct.