New Customer Application

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Billing Information

Name Title*

First Name*

Middle Initial

Last Name*

Social Security Number*

Email Address

Home Phone*

Work Phone

Cell Phone

Please choose one*I Own My Home I Rent

Delivery Address

Address Line 1 *

Address Line 2

City *

State *

Zipcode *

Former Fuel Supplier

Reason For Leaving

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Energy Products you would like to purchase

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Comments

I (we) hereby authorize Norbert E. Mitchell Co., Inc. ("Mitchell") to request consumer credit information from a consumer credit reporting agency in connection with my application for a charge account with Mitchell. I (we) further authorize ongoing procurement of the above mentioned reports (if necessary) should I be approved for an account with Mitchell. I acknowledge that if approved for a charge account with Mitchell, any past due amounts on my account will be subject to a PERIODIC RATE of 1.5% per month (an ANNUAL PERCENTAGE RATE of 18%). This authority will remain in effect until Mitchell is notified by me in writing to cancel it in such time as to afford Mitchell a reasonable opportunity to act on it.

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