J.C. Merriman, Inc.

Name

Birth Date

Address

Soc. Sec. #

City / State / ZIP

Email Address

Employment

Phone Number

Own, Rent, or Board

Own Rent Board

Number of Years

Spouse / Co-Applicant

Spouse's Name

Birth Date

Spouse's Employment

Soc. Sec. #

Email Address

Other Income

Additional Information

If sharing an apartment, other parties' names

Landlord's Name & Address

Landlord's Phone #

Former Fuel or Building Supplier

Products Interested in Purchasing

Fuel Oil Kerosene Propane Building Products

Additional Information for Fuel Accounts

Address Fuel Is Delivered To (if different from billing address)

Delivery Instructions / Description of Home

Product(s) Customer Uses

Fuel Oil Kerosene Propane

Hot Water

Yes No

Auto Delivery

Yes No

Tank Size

Tank Location

Fill Pipe Location

For Students Only

College

Year

Parent's Name

Parent Soc. Sec. #

Parent Email Address

Parent Phone Number

Parent Address / Employment

I/We certify that all information on this form is correct. I/We fully understand your credit terms and conditions and agree to proper payment in consideration of your extending credit. I/We further agree to personally guarantee payment in the event of nonpayment by the company.

Applicant Signature

Sign with your finger, stylus, or mouse.

Print Name

Date

Spouse Signature

Sign with your finger, stylus, or mouse.

Print Name

Date

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Customer Information Card