Customer Account Information
Address_________________________City__________Zip______________owner or tenant
Billing Address:-Check if same as Delivery Address. _______
Address________________________City __________Zip_______________owner or tenant
Credit Card Information
Type of credit card: Visa Mastercard Discover American Express (Circle one)
Name on card ____________________Credit Card Number ______________________
Expiration ________\_______ 3 Digit Security Code ____________(back of card)
_____ I agree to have automatic deliveries made to the address indicated above. I understand that as automatic customer I can expect deliveries based on temperature and past usage and I can not refuse a delivery. I also agree that my credit card may be charged for unpaid balances over 30 days or before next delivery whichever is sooner. I also agree to update my credit card information with Mansfield Oil & Energy Co., Inc. as the need arises. I understand I can cancel my automatic delivery in writing at anytime.
______I Authorize Mansfield Oil & Energy Co., Inc. to charge my credit card for fuel deliveries and/or service. I agree to update my credit card information as the need arises. I understand I may cancel this authorization, in writing, at any time.
Customer Signature Print name Date
Please Print & Sign as indicated – If you have Any questions – Please feel free to call.
945 East Street, Mansfield, MA. 02048