Residential Credit Application

Residential Account Application

ACCOUNT TERMS AND CONDITIONS Payment is due within 30 days of invoice date on open accounts. A finance charge of 1.5% per month (18% per year) will be added to all balances over 30 days. Any open account that becomes more than 60 days past due will be placed on cash-on-delivery status and will be subject to collection efforts, including a $25 service fee if past due goes to our collection agency. Customer will notify company of any address/phone number changes. Discounts of $0.05 per gallon plus tax will be granted on home heating fuels if payment is received within 10 days of the delivery, provided your account balance is current. If it becomes necessary for us to pursue legal action to collect a past due balance, customer will be responsible for paying all associated fees and costs, including reasonable attorney fees if applicable. All court proceedings will occur exclusively in Antrim County's 86th District Court.

First Name*

Last Name*

Billing Address*

Billing Address Line 2

Billing City

State*

Postal Code

Primary Phone

Secondary Phone

Email*

Date of Birth*

Social Security #*

Employer

Employer Address

Employer Phone Number

Spouse's Information

Spouse's Name

Spouse's Date of Birth

Spouse's SS# (if applying for joint credit)

Spouse's Employer

Spouse's Employer Address

Spouse's Employer Phone Number

Are you applying for credit? - By checking YES, you authorize Ellsworth Farmers Exchange to obtain additional information from credit bureaus and all other lawful sources regarding your credit history, and you certify that all information given on this form is true and accurate. If you check NO or do not check either box, your account will remain cash-on-delivery. PLEASE NOTE: Scheduled Delivery and Automatic Credit Card Billing programs require credit approval.*

Yes

By checking YES, you authorize Ellsworth Farmers Exchange to obtain additional information from credit bureaus and all other lawful sources regarding your credit history, and you certify that all information given on this form is true and accurate. If you check NO or do not check either box, your account will remain cash-on-delivery. PLEASE NOTE: Scheduled Delivery and Automatic Credit Card Billing programs require credit approval.

Date

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