Customer Account Information

Name_______________________________Social Security___________________________


Delivery Address:

Address_________________________City__________Zip______________owner or tenant

Billing Address:-Check if same as Delivery Address. _______

Address________________________City __________Zip_______________owner or tenant

Employment:

Employer________________________________Years there________________

Employment Address_____________________________Phone#____________

City_____________________State_______________Zip___________________

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)

Authorization (s)

_____ 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.

mo logo new 945 East Street, Mansfield, MA. 02048                

                                                                                                   1-508-339-4473