Customer Application

Applicant Name  

Social Security Number

Phone Number

 

Co-Applicant Name     

Social Security Number

Number of Dependents

 

Address                 City          St           Zip

 No. Yrs.

Own

Rent

Employer

Occupation    

Phone Number

 

Employer  Address

Monthly Gross   

Years Employed

 

Co-Applicant’s Employer

Occupation    

Phone Number

 

Co-Applicant’s Employer’s      Address

Monthly Gross   

Years Employed

 

Previous Fuel Supplier              Address

Account Number 

No of Yrs.     

Electric Provider                        Address

Account Number 

No of Yrs.     

Home Mortgage Holder           Address

Account Number 

Monthly Payment 

Auto Loan Holder                    Address

Account Number 

Monthly Payment 

Other Creditor                           Address

Account Number 

Monthly Payment 

Other Creditor                           Address

Account Number 

Monthly Payment 

The Federal Equal Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of sex or marital status. The federal agency which administers compliance with this law is the Federal Trade Commission.

I authorize Consolidated Energy Company to employ any credit bureau or other investigative agency to investigate the references listed herein, statements, or other data obtained from me or any other person pertaining to my credit and financial responsibility.  Consolidated Energy may make fuel deliveries into the equipment whether or not the consumer is present, and the consumer agrees to pay for such deliveries, even though the delivery ticket has not been signed by or for by the consumer.  If service is discontinued and you are due a refund for any gas remaining in the tank you will receive credit for the full purchase price less a service charge and any amount owed Consolidated Energy Company.

Applicant Signature:_________________________________________________

 

Co-Applicant Signature:______________________________________________

Date:________________

 

Date:________________

 

P.O. Box 317

Jesup, Iowa  50648

Phone 319-827-1211

Fax: 319-827-3154      

Nearest Relative Not Living with You           Phone

Applicant’s Mobile Ph #

Applicant’s Email Addr