Bainonline Creditapps

Residential Credit Application

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Application Date*

Name*

Social Security Number*

Street*

City*

State*

Zip code*

How long at this address?*

Email*

Home Phone*

Work Phone*

Mobile #

Beeper

Employer*

How long at this job?*

Billing Street (if different)

Billing City

Billing State

Billing Zip

Billing Phone

Applicant 2 (if Joint)

SSN (2)

Street (2)

City (2)

State (2)

Zip code (2)

Email (2)

Home Phone (2)

Work Phone (2)

Employer (2)

Landlord (if tenant)

Landlord Street

Landlord City

Landlord State

Landlord Zip

Landlord Home Phone

Landlord Work Phone

Previous Address: Street*

Previous Address: City*

Previous Address: State*

Previous Address: Zip*

Previous Phone*

How long at previous address?*

Nearest Relative (not living with you)*

Relative's Adress: Street*

Relative's Adress: City*

Relative's Adress: State*

Relative's Adress: Zip*

Relative's Phone*

Type of Delivery

Tank Location

Type of Oil

Special Instructions

How did you hear about Bain?

Applicant 1 Name*

Applicant 1 Sign Date*

Applicant(s) consents to a credit check based upon the information provided on this application for the purpose of extending credit. Applicant(s) further understand that the terms of this agreement will begin on the date of acceptance by Bain Oil Co., Inc. and will continue until either party terminates the agreement in writing. Our automatic delivery customers agree that use of this service does not nullify their responsibility to see that they have an adequate supply of fuel on hand. We expect payment each month and will apply a finance charge of 1.5% per month (18% annually) on a monthly basis to any balance remaining unpaid over 30 days. Our customers agree to pay all reasonable collection and attorney fees if legal proceedings become necessary to enforce collection.

Applicant 1 Agrees to the Application Terms*

Applicant 2 Name

Applicant 2 Sign Date

Application terms are at the top of this form

Applicant 2 Agrees to the Application Terms

Notes (internal use only)