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.

Name
First Last
Billing Address*
Street Address City State ZIP Code
Primary Phone
Secondary Phone
Email*
Date of Birth*
Social Security #*
Employer
Employer Address
Employer Phone Number
Spouse's Name
First Last
Spouse's Date of Birth
Spouse's SS# (Required if applying for joint credit)
Spouse's Employer
Spouse's Employer Address
Spouse's Employer Phone Number
Are you applying for credit?*
- Yes
- No
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 customers must either have an approved credit application or a valid payment method on file. Please complete the credit card authorization or electronic check form under the forms tab.
Date
MM slash DD slash YYYY