New Customer Application |
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| Not ready to become a customer? Click here to request more information. | |
| Fields with * are required. | |
| Billing Information | |
| * Name Title | |
| * First Name | |
| - Middle Initial | |
| * Last Name | |
| * Social Security Number | -- |
| * Home Phone | |
| - Work Phone | |
| - Cell Phone | |
| * Email Address | |
| * 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 | |
| - How did you hear about us? | |
| Energy Products you would like to purchase: | |
| Heating Oil | |
| Propane Used For | |
| Heating Service | |
| Air Conditioning Service | |
| Mitchell Manner Charge Card | See Gas Station and Conv. Store Locations |
| - 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. | |
| Click here if you agree with these terms: | |
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