Customer Credit Application Customer Name First Last Billing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Delivery Address Same as billing Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary PhoneDrivers License State & Number Current Employer Employer Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer PhoneType of employmentFull timePart TimeSeasonalSelf EmployedPrevious Employer If unemployed or retired, what are your sources of income? Gross monthly income ($ amount) Bank Name & Branch # Bank Contact Name First Last Bank Contact PhoneTotal of current and upcoming monthly long-term financial obligations (dollar amount) I certify that the above information is true and accurate and I have not misrepresented my financial status in any way. I understand that this is an application for credit and that a credit report may be obtained by Silver Valley Propane, Inc. in order to verify the above information. I will immediately notify Silver Valley Propane, Inc. of any changes to the information above in writing. I agree to pay any and all balances incurred with Silver Valley Propane, Inc. within 20 days from the date of billable service. I understand that I will incur finance charges for any unpaid balance after 30 -days at 1 ½% per month, not to exceed 18% per year or as applicable by law. Silver Valley Propane, Inc. reserves the right to attempt to collect any unpaid balance through any means allowable by law and to collect from me any reasonable costs associated with such collection. I understand that Silver Valley Propane, Inc. reserves the right to refuse, terminate, and/or limit credit at any time for any reason and may require prepayment or payment on delivery in the event this credit application is denied, has expired, or has been terminated.Signature Please type your full name.Date MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
