Company Information
Legal Company Name:
Doing Business As:
E-mail		Fax
Phone		Web Address

Delivery Address
Street:
City:		State:		Zip:

Own Building	Rent Building	Lease Expires:
If Owned, Under What Name:

Mailing Address (if different)
Street:
City:		State:		Zip:

References
Bank:		Account #:
Phone:		Fax:
Bank:		Account #:
Phone:		Fax:
Trade:		Account #:
Phone:		Fax:
Trade:		Account #:
Phone:		Fax:
Trade:		Account #:
Phone:		Fax:

Previous Fuel Supplier
Supplier:		Account #:
Phone:		Fax:
Reason For Changing

Chief Executive Officer Information
Name
Street:
City:		State:		Zip:
Phone:		Soc. Sec. #:

Chief Financial Officer Information
Name
Street:
City:		State:		Zip:
Phone:		Soc. Sec. #:

PLEASE READ CAFEFULLY

I hereby authorize Weaver Petroleum Inc., of Lititz, Pennsylvania ("Company") to make fuel deliveries on an Automatic Delivery Basis, or Will Call Basis, to the previously mentioned delivery address. I understand that "Will Call" orders must be called in to the Company 48 hours in advance of desired delivery time. I understand that with "Automatic Delivery" we shall receive fuel deliveries on an automatic basis (based on seasonal degree days) provided that there is no balance due at the time, current budget accounts excluded. It is also agreed that if payment is not received when due and if it is placed with an attorney or certified collection agency for collection, that the undersigned guarantor(s) will pay Company all costs of collection, including the sum equivalent to one third(1/3) of the amount referred to such attorney or collection agency, which the undersigned guarantor(s) agrees to be just and reasonable, or any amount which a court having jurisdiction shall determine to be just and reasonable, which shall be immediately added to the amount due. This guarantee may not be altered, modified, terminated, or waved orally, and shall continue in full force and effect until such time as you shall receive from the undersigned written notice of revocation shall not in any way relieve the undersigned from any indebtedness incurred prior to the actual receipt by Company at its corporate headquarters address, of such notice, and signed registry return receipt card shall be the best evidence thereof. Applicants(s) shall pay all bills from Company promptly upon receipt. If payment is not made in full within 30 days from the date of the bill, as to that amount which is unpaid, Applicant(s) shall be deemed in default and Applicant(s) hereby authorizes company to charge the maximum late/default charge permitted by law (currently in Pennsylvania the maximum permitted late/default charge is 1.50% per month on unpaid balance.) Company is hereby authorized to investigate all references or other information listed herein, including engaging of any credit-reporting agency to make a determination of the qualifications of Applicant(s) for an account. I (we) authorize any of our creditors, banks and other references to release all requested account information to Company. By allowing the customer to open an account with Company. Company is not extending credit or deferred payment. (PLEASE READ CAREFULY I (We) hereby certify that I (we) have read this form thoroughly on both pages and accept its conditions, and further state that all information supplied by me (us) is true in fact and intent.

I Agree I Do Not Agree

Heating Systems (check all that apply)

Oil Furnace	Oil Boiler	Oil Hot Water Heater
Gas Furnace	Gas Boiler	Gas Hot Water
Electric Hot Water	Heat Pump

Other Information:
Ticket should be left at which door:		Fill Location:
Fill Instructions:
Last time heating unit was cleaned:		Do you have central air?:
Last time A/C unit was cleaned:		Oil Tank Size/ Gal.:

Pay per Delivery	Pre Pay	Budget	Burner Service Contract	Installation