New Customer Application: No Lease

"*" indicates required fields

Account Name*

Mailing Address*

Street Address City State ZIP Code

Physical Address*

Street Address City State ZIP Code

Cell Phone

Home Phone*

Work Phone

Email*

Employer*

Spouse/Other Name

First Last

Cell Phone

Home Phone

Work Phone

Appliances Served

Do you own or rent your house?*

Own

Rent

Landlord's Name*

Main Phone*

Tank Info.

If there are current propane tanks on the property not included in this lease, please list them below.

Size

Serial Number

Make

Year

Size

Serial Number

Make

Year

CREDIT TERMS

Charges are due upon delivery. Any charges not paid by the 1st of the following month after delivery was made, will be subject to Finance Charges of 1.5% per month or 18% per annum. Failure to pay charges and/or Finance Charges may result in discontinuance in service and referral to collections. Customer agrees to pay all reasonable costs of collection, including attorneys fees and court costs. Payment plans may be available, but must be arranged prior to delivery of propane.

PURCHASE AGREEMENT

Customer must apply with all applicable regulations, standards and codes. Combustible materials, such as wood piles, building materials, other fuels and oils, etc. shall not be stored within 10 feet of the tank. Structures and sources of ignition shall be distanced from the tank as required by the LP gas code. The Customer shall notify Pirate Propane, Inc. should any repairs to appliances or the customers domicile be made or new appliances added to the system. By signing this agreement, customer claims that the serviceable propane tank is privately owned and not leased from another company.

Acknowledgement*

I/We agree to the CREDIT TERMS and/or PURCHASE AGREEMENT explained above.

Signature*

Date*

Spouse/Other Signature

Date